Why Does a Drug Need Pre-Approval?

Some drugs should be checked to make sure they are safe and used correctly. This may mean that a step called pre-approval (sometimes called prior authorization) is needed before it will be covered by your plan.

Like hospital stays and some types of procedures and treatments, some drugs need pre-approval. Your doctor’s office, using the information on your ID card, may tell you pre-approval is required for a certain drug. Or your pharmacy will let you know when it’s needed. Some reasons include:

• Side Effects: Does the drug have serious or severe side effects? Some steroids, pain relievers and sleeping meds have serious side effects for some people.
• It’s New: It may lack a long safety record.
• Misuse: Some drugs, like controlled substances, can be unsafe when not used the right way.
• Interactions: Is the drug unsafe when it’s combined with other drugs or over-the-counter medicines?
• Dose: Is the drug being prescribed as a higher dose than normal?
• Medical Necessity: Why did the doctor write the prescription? Is the drug needed for good health?
• Cost: Does an expensive brand-name drug have a lower-cost or generic version available that’s used for the same health problem?

When reviewing drugs and their use, we work with your doctor to make sure these things have been considered. It’s a good idea for you and your doctor to check your prescription drug list for covered options when making choices about how to manage your health.

Keep in mind that some drugs may not be covered. That may be because they are:

• Being used for a cosmetic rather than medical reason, like a face cream.
• Being used off-label. That means the drug was approved by the FDA to treat a specific health issue you don’t have. For example, using a diabetes medicine for weight loss by someone who hasn’t been diagnosed with diabetes.
• Available over the counter without a prescription, like an allergy medicine.

As new drugs become available, the pre-approval process helps you get a safe drug that works well at the lowest available cost. It helps keep health care safe, effective and affordable for our members.

Sources: Medication Safety Program,  Centers for Disease Control and Prevention, 2024; Use Medicines Safely,  U.S. Department of Health and Human Services, 2022; How to Obtain Prior Authorizations,  Breakthrough T1D (formerly the Juvenile Diabetes Research Foundation)

Originally published 10/13/2023; Revised 2024, 2025