Published: January13,2023
By Megan Pawlak, 2023 PharmD Candidate
Many patients have been to their pharmacy to pick up their medication, only to receive a call or be informed that their medication requires a prior authorization before it can be filled. This article describes why this might happen and explains what to expect if a prior authorization is needed.
What is a prior authorization?
A prior authorization is when an insurance plan asks for additional papers or information from the doctor or pharmacy before it agrees to pay for a medication or service. The prior authorization process involves multiple steps and can take some time to complete. Usually, insurance plans ask for prior authorizations when the quantity of a medication is high, the medication is unusual for a specific diagnosis, or it is very expensive. However, each insurance plan has different rules and requirements.
How do I know if my prescription requires a prior authorization?
It is difficult to find out if your medication will need a prior authorization, until your pharmacy submits the bill or claim to the insurance. When processing the claim, the pharmacy staff will get a rejection from the insurance saying that they need more information before they cover it. At that time, the pharmacy staff will contact your physician to help resolve the issue. The pharmacy will also let you know that the medication cannot be filled until the prior authorization is done. If you are concerned that your medication might require a prior authorization, you can always contact your insurance agent.
Why is there a prior authorization in the first place?
A prior authorization is the insurance plan’s way of making sure that your medication is needed and appropriate to treat your condition. It is in place to avoid overusing certain medications or to ensure that your doctor considers alternative medications. Your physician may need to verify the diagnosis, dose, frequency, and other relevant information. Once all requested information is sent to your insurance, they can then decide to approve or deny the medication claim.
Why is my prior authorization denied?
Your prior authorization can be denied for a few reasons. A few examples are included below:
- The insurance plan may need more information from your provider to decide.
- Your provider did not respond to the insurance plan’s request for more information.
- The medication is not being used for a condition that is formally approved by the Food and Drug Administration.
- Your insurance requires you to try other medications that have similar indications before they approve the claim.
- The medication is not covered as part of your plan.
What happens after my prior authorization gets denied?
If your prior authorization gets denied, you and your provider will get notified about the denial. You or your provider can contact the insurance for more information. Your provider can try to send in more documentation for reconsideration of coverage or change the therapy. Also, as a last option, you can independently try to appeal the request to your insurance for coverage of your medication.
How long does a prior authorization usually take?
The prior authorization process can range from a few days to a few weeks. This can depend on the urgency of getting the medication, the speed of the provider and insurance communicating, and the complexity of completing all the required steps. It is important to stay in contact with your physician and pharmacy on the progress of the prior authorization regularly and contact the insurance if requested.
Summary
A prior authorization is the insurance plan’s way of making sure that your medication is needed and appropriate to treat your condition. The prior authorization process can range from a few days to a few weeks. Be sure to talk to your doctor and your pharmacist if you need your medication right away.
