Prior authorization

How the process works

When a clinician prescribes something on your plan's prior authorization list, the office submits a request with your diagnosis, relevant labs and notes on what you have already tried. The plan compares that with its coverage criteria and approves, denies or asks for more information.

Many plans also use "step therapy," which requires you to try a less expensive option first. Brand-name weight-loss medications are a common example of drugs that need prior authorization, often with BMI and documentation requirements.

New federal rules

A Centers for Medicare & Medicaid Services rule (CMS-0057-F) applies to Medicare Advantage, Medicaid and CHIP programs and plans, and certain marketplace plans. Starting January 1, 2026, most of these payers must decide urgent requests within 72 hours and standard requests within seven calendar days, give a specific reason for denials and publicly report prior authorization metrics.

Two limits are worth knowing: the decision-deadline requirement does not apply to marketplace plan issuers, and the denial-reason requirement does not apply to drug prior authorizations. Employer plans follow their own rules and state laws.

If your request is denied

• Ask for the denial in writing and the specific criteria that were not met.
• Ask your clinician whether additional records, labs or a letter could address the gap.
• Request a peer-to-peer review, where your prescriber speaks with the plan's reviewer.
• File an internal appeal, and if needed an external review, within your plan's deadlines.

How it relates to cash-pay care

Prior authorization only applies when you are asking an insurer to pay. If you pay out of pocket, no plan approval is needed, though you lose the insurance discount and your spending may not count toward your deductible.

HealifyMD does not bill insurance, and compounded medications are generally not covered by health plans. For members using a brand-name GLP-1 through their own coverage, the Weight Loss Program Membership is from $75/month and provides clinical support; coverage decisions remain with your plan. Prices are confirmed at your eligibility review.

Tips to avoid delays

Keep a list of medications you have already tried, with dates and reasons you stopped, and share recent labs and measurements such as weight and BMI. Ask your clinician's office whether your plan uses an online portal, which is often faster than fax. Note the approval end date, because many approvals expire after a set period and must be renewed before you run out.