When you go to your local pharmacy to pick up your prescription, the pharmacist may tell you it is ready, BUT your insurance company will not pay for it because it needs prior authorization. Sometimes the pharmacy may tell you that your doctor’s office needs to “authorize the medication”.
Hopefully, the pharmacist explains to you why your medicine needs a “prior authorization” and that it is your insurance company delaying you receiving your medication. Often you may leave the pharmacy not knowing what to do or when you will be able to get your medicine.
Understanding ambiguous terms, such as prior authorization, is one of many problems our patients have when dealing with their insurance company and their changing medication formularies. Do you remember reading about prior authorization in your health insurance policy? Did you have trouble understanding why this authorization is needed?
Here are answers to some of the most commonly asked questions about prior authorizations. You should find this information helpful next time your medicine needs a prior authorization.
What is a prior authorization?
A prior authorization is an extra step that many insurance companies require before they decide if they want to pay for your medicine.
What medicines require a prior authorization?
- Brand-name medicines that have a generic alternative available. A generic medicine is a medicine that contains the same active ingredient as the brand name drug but is available at a lower cost.
- Expensive medicines
- Medicines with age limits. Retin-A®, a topical acne treatment, is an example. Acne is considered to be a condition of children and young adults. Retin-A® may not be covered if the person is over a certain age. This age can vary and is usually determined by the insurance company.
- Drugs used for cosmetic reasons
- Drugs prescribed to treat a non-life threatening medical condition. These drugs are usually not needed to maintain life. Some examples are erectile dysfunction drugs such as Viagra® and Cialis®.
- Drugs not usually covered by the insurance company, but said to be medically necessary by the doctor. Many different drugs can be used to treat the same condition. If a patient requires a particular medicine, the doctor must inform the insurance company that there are not other less expensive medicines that would work in the patient.
- Drugs that are usually covered by the insurance company but are being used at a dose higher than “normal”
What should I expect if my medicine needs a prior authorization?
If your insurance company requires a prior authorization on one of your medicines, it usually means the insurance company needs more information before they can decide if they want to pay it.
Becoming familiar with the prior authorization process may enable you to get your medicine approved faster. But beware, not all medicines will be approved. Even if you do everything right, the insurance company may still refuse to cover your medicine. In the end, the insurance company is the one making the decision.
What should I do if my medicine needs a prior authorization?
If the pharmacist tells you that your medicine requires a prior authorization then you should:
- Ask the pharmacist if they are creating and sending a Prior Authorization Request to the doctor who prescribed the medicine to let them know that your insurance company requires this for your medication?.
- Contact your insurance company and make sure there are no additional steps you need to take. Sometimes an insurance company may want you to fill out a form.
- Allow the doctor and insurance company enough time to process the Prior Authorization with your insurance company. (Your Insurance company may take 2-3 days to approve or deny a Prior Authorization for your medication.)
- Check back with the pharmacy to see if the prior authorization was approved.
- If your medicine is not approved, contact your insurance company to determine why.
What are some of the reasons why a prior authorization may not be approved?
- Your insurance denied your prior authorization claim
- You may not have provided your insurance company, doctor, and pharmacist enough time to complete the necessary steps.
- Your pharmacy may not be “billing” your insurance company properly. Sometimes when billing for a medicine that needs a prior authorization, a special billing code is needed. The pharmacy could have received an incorrect prior authorization code.
So you made it through the prior authorization process?
It’s over, right? Perhaps!
The process may need to be renewed each year, or possibly more frequently depending on your insurance company or plan.
Remember: Always be patient and tolerant with everyone working on your behalf. And don’t give up.