Jaclyn Mayo of Lunenburg, Massachusetts, found herself unable to refill a prescription for Zepbound, a medication that had significantly improved her balance and quality of life while living with multiple sclerosis. The issue wasn’t a change in her condition or a decision by her doctor, but an expired prior authorization requirement imposed by her insurance plan.
Mayo, diagnosed with MS, had been prescribed Zepbound, a GLP-1 medication initially intended for obesity, after diet and exercise proved insufficient to address her mobility challenges. “It was really helping me,” she said. “I could go up and down stairs and not feel like I was going to fall.” Beyond improved physical function, Mayo experienced unexpected benefits, including improved sleep and a reduction in numbness in her hands.
After seven months on the medication, her pharmacy refused to refill the prescription. A series of calls to her pharmacist, doctor’s office, and her insurance company revealed the problem: the initial prior authorization had lapsed. She learned this from the insurance company’s pharmacy benefit manager, a third-party administrator overseeing prescription drug plans.
Prior authorizations are a common requirement imposed by insurers, particularly for more expensive treatments, demanding that doctors justify the medical necessity of a drug before coverage is approved. Mayo was frustrated by the need for a new authorization so soon after the first, and stated she received no notification that the initial approval was nearing expiration. “Why do I need a prior authorization for something that I am already prior authorized to take? If my doctor says that they want me on a medication, why does my insurance have another say in that?” she asked.
Her physician submitted the necessary paperwork for a new prior authorization, but was informed it would take seven to ten business days for approval. During that period, Mayo’s symptoms returned, disrupting her sleep and bringing back the numbness in her hands. She requested an expedited review, but was told the request had to reach directly from her doctor.
The American Medical Association (AMA) has criticized the prior authorization process as “opaque and overly complex,” contributing to delays in care and increased administrative burdens for physicians. A recent poll indicated that one in three insured adults consider prior authorizations a “major burden” to accessing healthcare.
Experts suggest that GLP-1 medications, like Zepbound, are frequently subject to heightened scrutiny due to their cost. Miranda Aide of the University of Pittsburgh, who studies health politics and insurance administrative burdens, noted that the more expensive the treatment, the greater the likelihood of a prior authorization requirement.
To navigate the process, experts recommend proactively determining when prior authorizations expire by contacting the insurance company or pharmacy benefit manager. Building in extra time for potential delays is also crucial. Mayo’s experience highlights the importance of this, as she was without medication for over two weeks despite requesting a refill a week before her supply ran out.
Doctors can request expedited reviews, but the definition of “urgent” remains ambiguous, according to Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit. Federal regulations require a decision within 72 hours for urgent requests in employer-based plans, and a similar rule took effect January 1, 2026, for Medicare Advantage, Medicaid, and Children’s Health Insurance Program plans, though this does not currently apply to medications.
Exploring alternative treatment options can sometimes expedite the process, as health plans maintain formularies – lists of routinely approved medications. However, formularies are subject to change, potentially requiring new prior authorizations in the future.
Appealing a denial is also an option, with research suggesting a success rate of around 50%. Detailed documentation, including evidence of unsuccessful alternative treatments, can strengthen an appeal.
