Understanding Prior Authorization for Your Medications

What is Prior Authorization?

Prior authorization (PA) is a process where your insurance company must approve certain medications before they will cover them. This helps ensure the medication is appropriate for your condition, but it does mean there may be a waiting period before you can start your prescription.

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Important Timelines to Know

• Prior authorizations typically take 1–2 weeks to process after we submit them

• If your PA is denied and we appeal, appeals usually take 2–3 weeks

• Fax requests from pharmacies like CVS may take 1–5 days to reach our office

• All prior authorizations reset at the start of each year, so even if you were approved last year, we may need to submit a new request in January
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What You Need to Bring

Please bring your current insurance card to every visit. We need the following information from your card:

• Member ID

• Rx BIN

• Rx PCN

• Rx Group

 

Understanding Your Insurance​​

Different insurance companies have different requirements. Here's what you should know:

• IBC, BCBS, and PC have similar coverage rules

• Aetna, CVS, and Caremark are all part of the same company and share similar policies

• Highmark tends to be more restrictive for injectable medications (like GLP-1s and migraine injections)

• Tricare (Federal) requires the most detailed documentation

• Medicare does not cover weight loss medications regardless of your weight or BMI

 

Migraine Medications

• Nurtec / Ubrelvy: Most insurance plans require that you have tried and not had success with at least 2 triptan medications before covering these. You typically need to have 6–10 migraines per month to qualify.

• Aimovig (IBC/OptumRx): Requires trial of triptans, topiramate, and Depakote first. You'll also need documentation of other migraine treatments you've tried.

• Ajovy (OptumRx): Requires documentation of previous injectable migraine medication use.

• Emgality and other injectables: All require documentation that other medications have been tried without success.

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Weight Management GLP-1 Medications

Please note: Coverage for these medications has changed significantly. As of January 2026, many insurers have dropped coverage for weight loss alone.

 

Wegovy:
• Most often approved if you have significant heart disease history
• High cholesterol and high blood pressure alone are usually not enough
• Aetna/CVS plans are more likely to cover
• BMI of 35+ with 2 conditions OR BMI under 35 with significant condition

 

Ozempic:
• BMI of 30+ with 2 conditions
• Most commonly approved for Type 2 Diabetes or moderate/severe OSA

 

Mounjaro:
• Covered only for Type 2 Diabetes

 

Zepbound:
• May be covered for Obstructive Sleep Apnea
• IBC/OptumRx: BMI 35+ with 2 conditions
• Aetna/CVS: BMI 30+ with 2 conditions

 

Important: Even if approved, GLP-1 medications may be expensive with high-deductible plans.

Sleep Medications

• Diazepam: Requires trial of Lunesta, Zolpidem, and Trazodone first.

• Hydroxyzine: Often limited to 60 tablets per 30 days.

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Pain Medications

• Tramadol: First-time prescriptions are limited to a 7-day supply.

 

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Questions?

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If you have questions about a prior authorization or want to check on the status of a request, please contact our office. We're here to help you get the medications you need.