Clinical Scorecard: Understanding the Timelines of Prior Authorization to Prevent Interruptions in Care

At a Glance

Key Highlights

• Prior authorizations can expire, causing treatment interruptions if not renewed timely.
• Insurance companies require prior authorization to control costs and ensure evidence-based care, but the process can be complex and opaque.
• Patients and providers often face delays and administrative burdens, with limited communication about expiration and renewal timelines.

Guideline-Based Recommendations

Diagnosis

• Identify if prescribed medications require prior authorization based on insurance plan policies.

Management

• Physicians should submit prior authorization requests promptly and be aware of expiration timelines.
• Patients should proactively track prior authorization expiration dates by contacting insurance or pharmacy benefit managers.
• Request expedited reviews from physicians when medication interruptions pose urgent health risks.

Monitoring & Follow-up

• Monitor medication supply closely to avoid gaps due to prior authorization delays.
• Maintain clear communication between patient, provider, pharmacy, and insurer regarding authorization status.

Risks

• Delays in prior authorization renewal can lead to medication interruptions, worsening symptoms, and decreased quality of life.
• Lack of clear communication about prior authorization expiration increases patient frustration and risk of treatment gaps.

Patient & Prescribing Data

Patients with chronic illnesses requiring costly medications, such as GLP-1 agonists for weight loss in multiple sclerosis

Prior authorization expiration without notification can cause treatment interruption and symptom recurrence; proactive management and communication are essential.

Clinical Best Practices

• Educate patients about the need for prior authorization and potential expiration timelines.
• Encourage patients to contact insurers or pharmacy benefit managers to confirm authorization status.
• Physicians should anticipate prior authorization renewals and submit requests well before medication supply runs out.
• Utilize expedited review processes when clinical urgency exists, understanding insurer criteria and federal regulations.
• Advocate for clearer insurer communication and standardized prior authorization processes to reduce administrative burden.

References

• KFF Health News article on prior authorization timelines
• American Medical Association statement on prior authorization