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 36,454 prior authorization requests in 2024:

• 24,581 requests were submitted electronically, and 11,873 requests were not submitted electronically
• 29,185 requests were approved, and 7,269 requests were denied

Denied prior authorization requests

Of the 7,269 prior authorization requests we denied in 2024:

• 5,498 were related to pharmacy benefits, 1,654 were related to medical benefits and 117 were related to behavioral health benefits
• 7,269 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
• 6,746 denials were not appealed, and 523 denials were appealed. 429 denials were upheld on appeal, and 94 denials were reversed on appeal