Prior Authorization 

• Typically, physicians must fill out a prior authorization form whenever they prescribe a specialty medication or treatment that is restricted or not covered under an insurance carrier’s formulary. 
• Each insurance provider (insurer) uses its own unique form, and physicians may have to spend many hours familiarizing themselves with, and completing, dozens of forms of varying lengths and complexities. 
• As a result, prior authorization typically causes lengthy delays in treatment, thereby restricting a person's access to vital care. 

The Arthritis Foundation worked with the American Medical Association and other health care provider groups to establish twenty-one prior authorization principles, which include: 

• Establish a single, standardized form for physicians to submit prior authorization requests. 
• Establish electronic systems for the submission of prior authorization requests. 
• Require prior authorization requests to be completed by insurers within 48 hours of submission or receive automatic approval. 
• Once approved, permit authorizations to remain in place for up to 12 months for people with chronic conditions, such as rheumatoid arthritis (RA). 
• If a prior authorization request is denied, the member must be given clear instructions on how to file an appeal, including the information required and deadlines. 
• Provide a process for expedited appeals, especially for urgent care services. 
• Health plans should offer providers/practices at least one physician-driven, clinically-based alternative to prior authorization, such as, but not limited to, “gold-card” or “preferred provider” programs or attestation of use of appropriate use criteria, clinical decision support systems or clinical pathways. 

• Patients surveyed by the Arthritis Foundation in 2017 indicated that prior authorization was one of the top two most burdensome insurance issues. 
• In 2018, six organizations representing health care providers and health plans released a consensus statement to find opportunities to improve prior authorization programs. This collaboration builds upon the 21 principles outlined above. 
• According to a 2018 American Medical Association survey, which examined the experiences of 1,000 patient care physicians, nearly two-thirds (64 percent) report waiting at least one business day for prior authorization decisions from insurers – and nearly a third (30 percent) said they wait three business days or longer. 
• More than nine in 10 physicians (92 percent) said that the prior authorization process delays patient access to necessary care; and nearly four in five physicians (78 percent) report that prior authorization can sometimes, often or always lead to patients abandoning a recommended course of treatment. 
• A vast majority of physicians (86 percent) believe burdens associated with prior authorization have increased during the past five years. 
• Twenty-nine states have passed legislation requiring prescription drug prior authorization standards, including sixteen with electronic prior authorization standards.