How Prior Authorization Works for Infusion Therapy

If you've been prescribed an infusion medicine, you may hear the term "prior authorization," sometimes called pre-authorization or prior auth. It's one of the most common reasons treatment start dates move, so it helps to know what's involved.

What is prior authorization?

Prior authorization is a review your health plan does before it agrees to cover a specific medicine or service. The plan checks that the treatment meets its coverage rules for your diagnosis. Many biologic and specialty infusions require it, and approvals are often time-limited, so they may need to be renewed.

What the insurer usually asks for

• Your diagnosis and the medicine, dose and schedule your doctor ordered
• Recent office notes and relevant lab or imaging results
• Medicines you've already tried, and why they were stopped
• Required screening tests, such as tuberculosis or hepatitis B testing for some biologics

Some plans also require step therapy, which means trying one or more other medicines first. Others specify where an infusion can be given.

How long does it take?

Timelines vary by plan and by how complete the request is. Some approvals come back within days; others take longer, especially if the plan asks for more information. Missing records are one of the most common causes of delay, which is why we review every referral carefully before submitting.

How Infuse Care helps

Handling insurance is part of our care. When we receive a referral, our team:

1. Verifies your insurance benefits
2. Prepares and submits the prior authorization request, working with your doctor's office for any missing records
3. Follows up with your plan and keeps you updated
4. Schedules your infusion once approval is in place and the medication is ready

If your request is denied

A denial isn't always the final word. Plans often allow an appeal or a peer-to-peer review, where your doctor speaks directly with the plan's reviewer. We'll let you and your doctor know what the plan said, and work with your doctor's office on next steps.

Help with costs

Depending on your medicine and coverage, manufacturer copay programs or foundation assistance may be available. Eligibility rules vary. For example, many manufacturer copay programs aren't open to people with Medicare or Medicaid. Ask our team or your doctor's office what may apply to you.

Questions?

Call us at 732-444-8808. Patients can learn more in our insurance and FAQs section. If you're a provider, see how to refer a patient.