Prior Authorizations - Why Is My Medication or Test Being Delayed?

A Look Behind the Scenes at Prior Authorizations

If you’ve ever been told, “We’re just waiting on your insurance to approve it,” or “We need more information from your doctor,” then you have been trapped in a process called prior authorization (PA).

At Seeds of Health DPC, care should be clear, compassionate, and timely. But the reality of navigating insurance is that we often hit roadblocks—even when we know exactly what we need and why.

Let’s pull back the curtain on what’s happening when a prior authorization is required, and how you can partner with us to make the process smoother and faster.

💡 What Is a Prior Authorization?

A prior authorization is when your insurance company requires your doctor to get approval before they agree to pay for a medication, test, treatment, or procedure.

In theory, it’s meant to ensure appropriate use. In practice, it creates a frustrating delay in care for both patients and doctors, especially when the treatment is medically necessary and evidence-based.

🩺 What Happens Behind the Scenes?

From the outside, it might feel like everything is “on hold.” But here’s what’s happening in our clinic after your prescription or test order gets flagged for PA:

Certainly! Here's the same information reformatted as a clear, readable list—perfect for a blog post, email, or patient-facing handout:

🕒 What Happens Behind the Scenes During a Prior Authorization

When your prescription or test requires prior authorization (PA), here’s what we do on your behalf—and how long each step typically takes:

1. Notification (1–2 business days)
   We have been (hopefully) alerted by your pharmacy, lab, or imaging center that your insurance company requires prior authorization before covering the cost.

2. Chart Review (1 business day)
   My assistant and I review your medical history, recent symptoms, and treatment attempts to ensure we clearly explain why the medication or test is medically necessary.

3. Documentation (1–3 business days)
   We complete detailed insurance-specific forms, write a letter of medical necessity, and gather supporting materials, such as lab results, imaging reports, and visit notes.

4. Submission (same day)
   We fax or upload the whole packet of documentation to your insurance portal. Sometimes we have to submit it more than once if the system is delayed or incomplete.

5. Waiting Game (3–10 business days)
   The insurance company reviews your case. They may approve it, request more information, or issue a denial.

6. Appeal (if needed: add 5–7 business days)
   If denied, I may need to schedule a peer-to-peer phone call with an insurance medical director or submit a formal appeal letter with further documentation.

➡️ Total estimated timeline: 5 to 14 business days, depending on the complexity and how quickly your insurance responds. It can take longer if additional steps or appeals are required.

💊 Common Medications That Often Require PA

Even when the need is obvious, insurers may delay coverage for:

• Ozempic, Wegovy, Mounjaro (for diabetes or weight loss)

• Testosterone therapy

• CGMs (continuous glucose monitors)

• Newer ADHD or antidepressant medications

• Certain inhalers, injectables, and biologics

🧪 Tests & Services That May Require PA

• MRIs, CTs, PET scans

• Sleep studies

• Specialty labs (like GI-MAP, DUTCH, or pharmacogenomic testing)

• Infusions or high-cost injections

• Physical therapy or specialist referrals

Any procedure other than an ultrasound or X-ray essentially requires pre-approval from your insurance.

These are not fringe treatments—they’re often standard of care. However, cost or insurance policies can still trigger a PA.

🤝 How You Can Help Us Help You

You are not powerless in this process. In fact, there are specific ways you can speed things up and strengthen our case:

1. Share your full symptom story
   Be specific about when symptoms started, how they affect daily life, and what has or hasn’t helped.

2. Let us know what you’ve already tried
   If this is a medication PA, list any other drugs or treatments you’ve used, and whether they worked or caused side effects. (Even “it didn’t help much” is useful.) Insurance requires us to disclose this information, even though they should already have a record of it. They want to know the medication, dose, when you took it, and for how long, as well as any side effects or reactions you experienced.

3. Be open to a “trial” medication.
   Sometimes insurers require a step-wise approach: trying a lower-cost option first before approving the one we want. We can guide you through this if needed.

4. Watch your insurance portal or mail.
   Occasionally, you may get notifications before we do. Share any approval or denial letters you receive.

5. Consider out-of-pocket options
   Sometimes the cash price (via GoodRx, Mark Cuban’s Cost Plus Drugs, or our in-office pharmacy) is cheaper than using insurance, without any wait.

💬 A Note from Dr. Angela

When we prescribe something, it's because I believe it's the right step for your health, not because of trends, pressure, or shortcuts. We don’t get any kickbacks from pharmaceuticals for your medications (nor do most doctors, for that matter). 

And when insurance makes us jump through hoops, it doesn't mean you're not sick enough, or don't qualify—it means the system is flawed. But I will continue to advocate for you, document thoroughly, appeal when needed, and push back—because your health is worth it.

If you’re stuck in the PA process now, or the pharmacy has just told you that something “needs approval,” please don’t hesitate to reach out. We’re in this together—and we’re fighting for your care every day.