Prior authorizations can feel confusing, but your FOLX care team handles the heavy lifting. Learn how insurance prior authorization works for hormone therapy, gender-affirming surgery, and more.
Insurance can feel like a maze — especially when all you want is your medication. Here’s how prior authorizations work, what your FOLX care team handles for you, and what to do if things don’t go as planned.
What Is a Prior Authorization?
A prior authorization (sometimes called a “prior auth” or “PA”) is your insurance company’s way of saying: before we agree to help pay for this, we need to review it first. It’s not an automatic denial, even though it can be hard to wait. Think of it as a speed bump, not a stop sign.
Not every insurance plan requires a prior authorization, and not every plan covers the same medications or treatments. The quickest way to find out what your plan requires is to call the member services number on the back of your insurance card or chat with your insurance provider via their website or mobile app.
How Does the Prior Authorization Process Work at FOLX?
When a prior authorization is needed for a prescription, your pharmacy will fax a request to your FOLX care team. Then your FOLX care team will work with your insurance to complete the request. This can include answering questions about your medication start date, giving your insurance your diagnosis code, and any other clinical information they require to make the decision that the medication your provider has prescribed is medically necessary and fits your insurance’s criteria for coverage.
Prior authorizations are also sometimes required for non-prescription healthcare. For example they might be required for gender-affirming surgeries or in-person appointments with specialists like dermatologists. For those, your care team will gather the date of service and any additional clinical information needed.
What We Might Need From You
Your FOLX care team may reach out and ask for:
- A photo of the front and back of your insurance card
- A photo of your pharmacy benefits card, if separate (or just the pharmacy benefits ID number)
- The address where your insurance is registered, if it’s different from what we have on file
Heads up: If you’ve moved since enrolling in your insurance plan and haven’t updated your address with them, send us the old address — that’s likely what’s linked to your benefits.
How Long Does a Prior Authorization Take?
Once submitted, it can take up to 14 business days to hear back from your insurance company. Some plans move faster. The timeline depends entirely on your insurer — not on FOLX.
If Your Prior Authorization Is Approved
If your prior authorization comes back approved, great! This is the outcome we’re always working toward. An approval means your insurance will cover a portion or all of the cost of your medication or treatment.
Once your care team lets you know you’re approved, you’ll need to contact your pharmacy and ask them to re-run your prescription through insurance. They’ll let you know when it’s ready and what your copay will be.
Keep in mind: Prior authorizations are typically valid for six months to a year. When yours expires — or if you change insurance — your care team will need to resubmit. Your provider usually prescribes a 90-day supply, but some insurance plans only cover 30 days at a time. If that’s the case, you’ll need to contact your pharmacy each month for refills.
If Your Prior Authorization Is Denied
Denials happen, and they’re frustrating. It doesn’t mean your care isn’t valid — it means your insurance has decided, based on their criteria, not to cover it right now.
Common reasons for denials include: your plan doesn’t cover the specific medication, there’s a quantity limit, or your insurer requires you to try a different medication first. Sometimes they require certain lab results to be within a specific range before approving.
Your Options After a Denial
A denial isn’t a dead end. Here’s what you can do:
- Appeal: Your FOLX care team can file an appeal on your behalf. These typically take an additional 7–14 business days, and unfortunately they are not often successful.
- Pay out of pocket or use a discount: You can pay for your medications directly, or use a coupon from GoodRx. If you find a different pharmacy with better pricing, you can let us know, and we’ll send your prescription there.
- Use FOLX’s partner pharmacy: Our mail-order pharmacy offers transparent pricing. View the current price list at folxhealth.com/price-list.
- Explore mutual aid: There are grants and funds available that may help cover medication costs. Browse resources at folxhealth.com/library/mutual-aid-funds.
The Appeals Process
If your care team files an appeal, the process typically takes a minimum of 30 days — that’s an insurance timeline, not ours. Depending on the insurer, appeals may be submitted through an online portal, by phone, or by faxing additional clinical documentation.
In some cases, an appeal isn’t possible — for example, if your plan explicitly excludes coverage for a specific medication under your diagnosis code. If you’re unsure about what your plan covers, calling your insurance’s member services line is the best move.
If the appeal is denied, your provider may be able to do a peer-to-peer review — a conversation between your FOLX provider and the insurance company’s medical reviewer about the medical necessity of your care. These are typically a last resort and don’t always result in approval, but they’re another tool in the toolkit.
If you’ve exhausted the appeals process and have questions about the decision, reach out to your insurance company directly for more information.
Common Questions About Prior Authorizations
How do I know if I need a prior authorization?
The fastest way to find out is to call your insurance company using the member services number on the back of your card. If one is needed, your pharmacy will fax the request to your FOLX care team, and we’ll let you know it’s in progress.
What if I don’t want to use my insurance?
That’s completely fine. Some members prefer to pay out of pocket — whether for privacy, simplicity, or because they’re on a family member’s plan. Just let your pharmacy know, and they’ll process your prescription without running it through insurance. You can also use FOLX’s partner pharmacy for transparent pricing.
My prior authorization was approved, but the pharmacy only gave me a 30-day supply. Why?
Some insurance plans limit dispensing to a 30-day supply at a time, which is especially common with testosterone since it’s classified as a controlled substance. Your provider may prescribe a 90-day supply, but you’ll need to contact your pharmacy each month for your next refill. If you’d rather receive your full 90-day supply at once, let your pharmacy know.
My insurance denied my prior authorization even though they approved it before. What happened?
Insurance companies can change their coverage criteria without notifying members. If a previously approved medication gets denied, call the member services number on your card for details. Your FOLX care team can also help you understand your options, including filing an appeal.
How much will my medications cost with insurance?
We wish we could tell you ahead of time! Costs vary depending on your plan, your pharmacy, and your specific medication. Once your prior authorization is approved, your pharmacy or insurance provider can tell you your exact copay amount.
Your FOLX care team advocates for your coverage every step of the way. If you have questions about a prior authorization — or anything else about your care — reach out through your member portal.
