Prior authorization reporting

As part of our coverage criteria and drug list (formulary) policies, some services and medicines require prior authorization before our health plans cover them. Every year, we post details about the prior authorization requests we received the previous year and how we responded to them.

Total prior authorization requests

We received 34,665 prior authorization requests in 2023:

• 22,422 requests were submitted electronically, and 12,243 requests were not submitted electronically
• 28,221 requests were approved, and 7,444 requests were denied

Denied prior authorization requests

Of the 7,444 prior authorization requests we denied in 2023:

• 5,696 were related to pharmacy benefits, 1,656 were related to medical benefits and 92 were related to behavioral health benefits
• 7,444 were denied because the patient did not meet prior authorization criteria, 0 were denied due to incomplete information submitted by the care provider, 0 were denied due to a change in treatment program and 0 were denied because the patient was no longer covered by a plan
• 6,926 denials were not appealed, and 518 denials were appealed. 429 denials were upheld on appeal, and 89 denials were reversed on appeal