A prior authorization can be frustrating and confusing.
You go to the pharmacy to fill a prescription.
You provide your insurance information to the pharmacist and wait for them to process everything as usual.
Unfortunately, this time the pharmacist informs you that a prior authorization is required.
What’s the deal?
After all, you’ve filled plenty of prescriptions before without any issue.
What’s a prior authorization and why does it only affect some medications and not others?
What is a Prior Authorization?
Simply put, a prior authorization, also known as a pre authorization or prior auth, is when a specific medication requires special approval from your insurance company before they will offer full or partial coverage for payment.
In other words, your insurance company won’t help pay for the drug until they have reviewed the circumstance.
Generally speaking, prior auths are required for more expensive medications.
Prior authorizations require approval of coverage from your insurance company, not your doctor.
Why Do Insurance Companies Require Prior Authorization?
In short, health insurance companies use pre-authorizations to keep costs low.
This might sound like a negative but it can actually be a good thing.
For example, imagine you have two medications that each treat the same condition.
One is a brand name drug and the other is an identical generic which costs significantly less.
If your doctor prescribes the more expensive brand name drug, the insurance company just wants an explanation, a prior auth, before they pay for it.
When the explanation is acceptable to your insurance then the prior auth will be approved.
When the explanation is not acceptable to your insurance, then your doctor can switch you to the alternative or you can choose to pay for the brand name drug without insurance.
This helps insurance companies keep costs down which in turn makes health insurance plans more affordable for everyone.
What Kinds of Medications Need Prior Authorization?
There are several reasons why an insurance company may require a preauthorization for a medication.
Here are a few:
- A brand name medication has an identical generic alternative
- The medication is only for cosmetic reasons
- A medication is not preventative or used for non life threatening conditions
- The medication is only for specific age groups or conditions
- A medication could have adverse health effects, dangerous interactions, or risk for abuse
In these situations, a preauthorization just allows the insurance company to verify that a medication is appropriate.
Who is Responsible for Completing a Prior Auth Request?
Most of the time, your doctor is responsible for initiating a prior authorization.
They fill out a prior authorization form and submit it to your insurance company. Then, your insurance company reviews it and either approves or denies the request.
However, this is not always the case.
For example, at NowRx Pharmacy we assist our doctor offices in filling out the prior authorization form.
This helps expedite the process for the patient, in addition to saving the doctor office’s staff time and energy.
This is rare as most retail and mail order pharmacies will require your doctor to complete the prior authorization on their own.
Unfortunately, that often results in delays with the patient receiving their medication.
How Long Does it Take to Get Prior Authorization for a Prescription?
The speed of a prior authorization can vary drastically from hours to days depending on a number of factors.
These factors include things like how it was submitted (call, fax, etc.), when it was submitted, the length of the review process, whether additional information is needed, etc.
Ultimately, the faster your doctor (or pharmacy) can submit the prior authorization, the faster you will receive a decision.
What Can I Do If My Prior Authorization is Denied?
If your request is rejected, you or your doctor can ask for a review of the decision.
Your doctor may be able to provide backup documentation or medical notes. These can help prove to your insurance company why the specific medication is medically necessary.
If you appeal and your request is still denied, there are still options.
You can always switch to a different medication or pay cash (i.e., out of pocket).
This situation is not ideal, but depending on your insurance plan it may count towards your deductible.
Prior Authorization for Medication
Ultimately, prior authorization is an annoying but necessary part of health insurance.
It helps keep health insurance costs down which in turn makes health insurance plans more affordable for everyone.
It may feel frustrating at the time but speak with your primary care provide if you have questions or would like to explore other options.
About NowRx Pharmacy
NowRx Pharmacy is a new kind of local pharmacy built from the ground up to deliver a better pharmacy experience. We use modern technology inside the pharmacy to provide better pricing, better service, and better convenience. Visit our NowRx Pharmacy Frequently Asked Questions to learn more.