Prior Authorization Is Not A Four Letter Word (...literally)

Customer: "My doctor ordered the medication, just fill it and I will be on my way."
Pharmacist: "Sir, unfortunately, your prescription insurance does not want to pay for this specific medication, we need to have your doctor contact the insurance company and request a Prior Authorization for your prescription."

Customer: "I don't understand, my doctor already authorized the medication, you have a prescription for it don't you?"...and on it goes...

This is a conversation scenario we have all too often in the pharmacy.  A patient comes in with a prescription for a medication that is not covered by their insurance and we need to take some time to help the patient understand the process that needs to happen.  It helps to have a little understanding of Prior Authorizations, Formularies, Medical Necessity and what you as a patient can do to help the process move forward.

Your insurance company, in its great wisdom, will decide which medications are covered under your prescription plan.  This list of medications is called the Formulary.  The formulary is usually categorized into 3 or 4 different levels, (or tiers).  The first tier is usually the generic medications which are covered at the lowest set copay.  The second tier is usually the brand name medications that the insurance company has contracted with at a higher copay.  The third (or fourth) tier, depending on the insurance company, is usually the medications that are not covered or have some specific limitation on them.  These are the medications we are talking about in this discussion, the medications that require prior authorization.

There are a few different reasons why a medication would require prior authorization.  They all involve documentation from the physician stating the specific medical necessity of the non covered medication.

                1.  Perhaps there are choices already covered by the insurance that are therapeutically equivalent and the insurance would like documentation from the doctor as to the medical necessity of why the formulary alternatives cannot be used.   

                2.  Perhaps the medication is on formulary and is covered; however, the physician wants the patient to take the medication more often than it is usually prescribed.  For example, the usual dose may be once daily; however, the doctor wants the patient to take the medication twice daily.  The insurance needs documentation as to the medical necessity of this dosing regimen.

                3.  Perhaps the medication is on formulary, however, there are age or gender limitations which need to be addressed by the doctor to show that this particular medication is medically necessary for this particular age or gender.

                4.  Perhaps this is a very expensive medication and there are no other therapeutic alternatives, however, the insurance company needs to document the appropriate diagnosis through prior authorization before they will approve the filling of the medication.

These are just the most common examples; however, I know I have come across numerous different situations over the years.  This is a process and there is hope.  There are a few things you can do as a patient to help the situation along.

First, ask your pharmacist if there is a formulary alternative that might be appropriate to switch to.  Quite often this is a simple fix.  Your pharmacist could easily phone your doctor and suggest an alternative that is covered by your insurance.

If there is no formulary alternative available, or, if you have tried the formulary alternatives and they were not effective or you could not tolerate them for some reason, then a prior authorization will be necessary. 
First, your pharmacist will complete the required documentation with the name of the drug, your insurance information, the insurance phone number and a note to your doctor describing that this medication needs prior authorization.  The pharmacy will then fax the note to your doctor.  If the situation is urgent, the pharmacy may call the doctor's office and explain the situation and the urgency.

At this point, we need to wait for the doctor's office to contact the insurance company and do their part.  Once they have submitted the appropriate documentation, then the insurance company will review the request and either approve or deny authorization. 

Here is where you as a patient can help move the process along.  It is appropriate to give the doctor's office a day to get the paperwork filed with the insurance company.   After 24 hours you could then call the doctor's office and pleasantly ask them if they have submitted your prior authorization request to your insurance company.

Once the authorization has been submitted, you may then call your insurance company to make sure they understand the importance of completing this as soon as possible for you.  If you are having trouble with the person you are speaking with, it is perfectly appropriate to ask to speak with someone else. 

After having spoken with pharmacy insurance representatives over the phone for over 25 years, I can tell you that maintaining a pleasant attitude with the representative on the phone really helps move the process along quicker.  Always be sure to write down the representative's name that you spoke with so that if follow-up is necessary, we know who to ask for. 

Once authorized, the insurance company codes your profile in the computer so that the pharmacy may then process the prescription.

It is important to realize that at any point during this process you do have the option of paying cash for the prescription.  The prior authorization is only to get your insurance company to pay their portion.  If you pay cash for your prescription, it may still be prudent to pursue a prior authorization so that you may get reimbursed for your payment.  The important item to note is that if you pay cash, your prior authorization must be retroactive to the date that you purchased your prescription. 

I hope this helps you understand a little of what we go through in the pharmacy trying to get your prescriptions covered by your insurance.  Please feel free to comment if you have any other great tips for working with insurance companies about prior authorizations!


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