A Guide to Prior Authorizations for Sunrise Patients

You’ve probably come across the term “prior authorization” (PA) at some point, as these insurance-mandated coverage approvals have become increasingly common in healthcare. If you find PAs frustrating to navigate or aren’t sure who does what to move the PA process along, you’re far from alone. Here’s what every patient should understand about PAs — and how Sunrise manages and simplifies the process. 

What’s a prior authorization?   

A prior authorization is a process where your insurance company requires confirmation of the medical necessity of a prescribed medication before deciding whether or not to cover its cost. Almost all insurance plans require PAs for GLP-1 medications such as Wegovy, Saxenda, Ozempic and Mounjaro. Insurance companies can also require PAs for other types of treatments and services. This process is also referred to as “Pre-approval,” “pre-authorization” and “prior approval”. 

To secure a PA approval, your doctor needs to submit paperwork to your insurance company that explains why you’ll benefit from the medication. 

As a Sunrise patient, you will not have to file your own PA, regardless of what your plan permits. Sunrise patient representatives, who are in communication with providers, take care of the whole process. If they need to clarify something about your medical history, they might contact you for additional information regarding your medical history. 

What triggers a prior authorization?

Certain medications, like GLP-1s, almost certainly require prior authorization. Doctors typically know which medications are likely to require PAs. In some cases, a doctor’s office might send a prescription to a pharmacy and wait to hear that a PA is required before submitting paperwork to the insurance company.

Sunrise adopts a more proactive method. To expedite getting insurance coverage for you, Sunrise representatives start communicating with your insurance company as soon as your prescription is written. The goal is to submit your PA within 24 hours of your visit, provided all your information is available.

It is important to note that your pharmacy will receive your prescription before your insurance company makes a coverage decision. So your pharmacy might call you, or you might see a prescription status update that says “prior authorization required” or “waiting for insurance approval.” If that happens, don’t worry — we know about the PA and we’ve already taken action on your behalf. Also, be aware that if your pharmacy quotes a medication price at this stage, it may be high because it could reflect the cost without insurance coverage.

Once we submit your PA, your insurance company will review it to make a coverage determination. This usually happens within three days, but it can take longer.

Why would insurance deny a prior authorization?

If your insurance company denies coverage for your medication, they’ll explain why in a denial letter. They might only send this explanation to Sunrise, or they might email or mail it to you as well.

At a high level, there are two reasons for GLP-1 denials:

• A plan exclusion: As a rule, some plans don’t cover GLP-1 drugs as weight loss drugs. If your plan has a categorical coverage restriction, the denial is probably set in stone.
• A high documentation barrier: Some plans require more evidence of medical necessity than others. If your plan denies coverage for this reason, Sunrise might be able to appeal the decision by supplying additional information.  

If Sunrise can’t appeal a denial, are there other options? 

If your insurance company won’t cover a brand-name GLP-1, Sunrise will help you find an alternative treatment plan. Here are some options for next steps:

• We’ll work with your insurance to figure out which treatment alternatives they will cover that are clinically effective for you.  
• You may qualify for certain patient access programs provided by the pharmaceutical companies themselves. These programs can help you reduce your out-of-pocket costs significantly, and we’ll evaluate whether you’re a good fit for them.
• Your physician will work with you to identify other treatments that are effective and affordable, even without insurance coverage. One possibility might be compounded Semaglutide, a generic medication with the same active ingredient as Wegovy and Ozempic.

Your PA flowchart 

Though the details of the PA process vary from one insurance company to the next, here are the basic steps for Sunrise patients: