Can Patients Initiate Prior Authorization for Drug Approval?
Patients cannot directly initiate the prior authorization (PA) process themselves—this must be done by their healthcare provider (physician, pharmacist, or other authorized prescriber), though patients can and should actively advocate for their care by requesting their provider to submit the PA. 1
The Standard Prior Authorization Process
The PA process is fundamentally a provider-driven administrative requirement:
Healthcare providers (physicians, pharmacists, nurses) are responsible for submitting PA requests to insurance companies on behalf of patients, as this requires clinical documentation and prescriber credentials that patients do not possess 1
The process requires multidisciplinary clinical teams including pharmacy professionals and nurses experienced in navigating the complexities of PA requirements and insurance approval processes 1
Pharmacist-initiated PA processes have been successfully implemented in various healthcare settings, demonstrating that non-physician providers can effectively manage this process 2, 3
What Patients CAN Do
While patients cannot submit PAs directly, they have important roles:
Patients can request their provider to initiate the PA process and should do so promptly when informed a medication requires authorization 4, 5
Patients can provide necessary documentation such as income verification for patient assistance programs, though this is separate from the clinical PA submission 5
Patients can work with pharmacy professionals who can help navigate insurance coverage and patient assistance programs alongside the PA process 4, 5
Patients have the right to appeal PA denials through reconsideration appeals, though this still requires provider involvement to submit additional clinical documentation 4
The Administrative Burden Reality
The complexity of PA creates significant barriers:
Many large referral centers employ dedicated staff members (nurses or pharmacists) solely to navigate the PA process, which requires hours of uncompensated time that is often only financially feasible in larger academic practices or integrated health systems 1
Smaller health systems and community practices struggle with the logistics of therapy initiation as PA requirements demand extensive staff time without compensation 1
The average PA processing time ranges from 0.53 to 7.02 days depending on whether specialized pharmacy-led PA services are available, with approval rates varying from 68% to 93% 3
Practical Steps for Patients
When facing PA requirements, patients should:
Immediately contact their prescribing provider to request PA initiation, as delays can negatively impact outcomes 5
Engage with pharmacy staff at their healthcare facility, as pharmacists often have expertise in PA navigation and can expedite the process 4, 5
Be prepared to provide insurance information and any requested documentation to support the provider's PA submission 4
Document all communications regarding the PA process for their records 4
Common Pitfalls to Avoid
Do not assume the PA will be automatically processed—patients must verify their provider has submitted the request 6
Do not wait passively for approval—follow up with both the provider's office and insurance company to track progress 5
Do not accept initial denials without question—providers should appeal decisions contrary to best patient care, and patients should request this action 4, 5