What is a Prior Authorization for a Prescription?
You go to the pharmacy to fill a prescription.
You provide the prescription, your insurance, and wait for the pharmacist to process everything and charge you for the medication like usual. Unfortunately, this time they tell you that a prior authorization is required from your insurance in order to cover the medication. This can be confusing and extremely frustrating to hear. After all, you’ve filled plenty of prescriptions before and never had this issue, what’s the deal? What’s a prior authorization and why does it only affect some medications and not others? Here is everything you need to know.
What is a Prior Authorization?
Simply put, a prior authorization 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 authorizations are required for more expensive medications as a way for the insurance provider to manage medication costs both for themselves and their insured. 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 prior authorizations, also called pre-authorizations to keep costs low. This may sound like a bad thing, but not always. Imagine you have two medications that each treat the same condition, except one is a generic medication and the other is a brand name drug that costs both you and the insurance company twice as much. If your doctor prescribes the more expensive brand name drug, the insurance company just wants an explanation before they pay for it (i.e. a prior authorization). When the explanation is acceptable to your insurance, for example maybe your doctor believes the brand name is more effective, then the prior authorization 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 reduce unnecessary costs and keep their health plans affordable for everybody.
What Kinds of Medications Need Prior Authorization?
There are several reasons a medication may require a prior authorization request. Insurance companies will usually require prior authorizations for the following medications:
- Brand-name medications that also have a generic available.
- Medication used only for cosmetic reasons
- Drugs that are neither preventative or used to treat non-life-threatening conditions
- Medicines intended for certain age groups or specific conditions only
- Prescriptions that could have adverse health effects, dangerous interactions, or risk for abuse
Who is Responsible for Completing a Prior Auth Request?
Most of the time, your doctor will be responsible for initiating a prior auth request. They will initiate the request to your insurance company on your behalf. Your health insurance will then review the doctor’s recommendation and either approve or deny the prior-auth request. In some cases, your insurance will ask for additional information from your doctor before they decide. Some pharmacies, like here at NowRx Pharmacy, will assist and even complete the process for your doctor with the process but this is extremely rare. Most brick & mortar as well as mail order pharmacies require your doctor to handle prior auths by themselves which results in longer delays.
How Long Does it Take to Get Prior Authorization for a Prescription?
The speed of a prior authorization can vary drastically from minutes to days depending on a number of factors. These factors include things like how the prior auth is submitted (call, fax, etc.), when it is 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 Auth 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. Speak with a trained healthcare professional to figure out what the best option is for your specific circumstance.