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Benefits Authorization for LA ART
Let’s Figure It Out! Problem-Solving in Benefits Authorization for Long-Acting ART

Released: June 25, 2026

Larisa V. Niles-Carnes
Larisa V. Niles-Carnes, MPH
Activity Information

Activity

Key Takeaways
  • Successful benefits authorization for long-acting antiretroviral therapy takes persistence, knowledge, and being savvy with billing.
  • Be ready to investigate denials or rejections, appeal, and find alternative routes when the first benefits or billing pathway does not work.

I have worked at Grady Health in Atlanta, Georgia for 12 years, and in HIV for more than 20 years, and seeing the evolution of HIV treatment has been very inspiring. For some people, pill burden, dysphagia, and stigma have been huge barriers to antiretroviral therapy (ART) adherence for a very long time. To be part of something as revolutionary as implementing long-acting (LA) ART has easily been one of the biggest joys of my entire existence. Helping to build Grady Health’s LA ART program was a major undertaking, but I hope our success will show you that setting up your own program is an attainable goal.

We originally billed LA ART under pharmacy benefits, but we later moved to billing under medical benefits because the healthcare system was able to be reimbursed for more of the services. That has been fairly convenient, but we had to coordinate with an entirely new department to get benefits authorization. We had to revisit how we work and communicate with them, and we had to proactively advocate for patients in the authorization queue.

Don’t Take No for an Answer
Obtaining authorization for LA ART can be challenging, so it is important to be able to pivot when one road to drug access has been blocked. We do not stop when we get a denial, because our patients need ART. My mantra with insurance companies is that I do not take No as an answer. When I hear No, I immediately try to figure out how to get a Yes. Sometimes this means submitting an appeal. Other times, it means engaging in peer-to-peer discussion with the insurance company.

No matter the approach, what it truly takes to turn No into Yes is persistence and knowledge. We must remember that we are subject matter experts, and we must be able to explain the benefits of these medications to people working at insurance companies who may or may not have infectious disease expertise. I also find it helpful to use real-life examples to illustrate why a patient would benefit from LA ART.

Keep Current
Another challenge is staying up to date with patient insurance. Sometimes, patients themselves are unaware that their insurance has changed. We are still in the process of addressing this issue, but part of the solution is better communication across departments, including patient access representatives and the financial counseling team. Rather than manually documenting everything in massive spreadsheets, we have moved to using a population health program to track what needs to be done and when.

Connect With Others
If you are interested in implementing LA ART, I think the first step is reaching out to organizations that are already doing it. We have been there and can provide blueprints for getting started and SOPs to help you along the way. Of most importance, reaching out opens that line of communication for troubleshooting if problems arise.

In all, benefits authorization for LA ART is a marathon. It requires perseverance and resourcefulness. If you get stuck, try something new or ask for help!

Your Thoughts
What questions do you have about benefits authorization for LA ART? Leave a comment to join the discussion!