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A Quick Lesson on Prior Authorization

Annie Rick, PharmD Candidate 2007
The Ohio State University College of Pharmacy, Columbus, OH
Prepared during Consumer Health Information Corporation Clerkship

McLean, VA

Has this ever happened to you? You walk into your local pharmacy to pick up your prescription. The pharmacist tells you it is ready, BUT your insurance company will not pay for it because you need a prior authorization. The pharmacist explains to you why your medicine needs a prior authorization. Somehow, you still end up leaving the pharmacy not knowing what to do or when you will be able to get your medicine.

Understanding complicated terms, such as prior authorization, is one of the major problems people have when dealing with their insurance company or pharmacist. Do you remember reading about prior authorization in your health insurance policy? Did you have trouble understanding the material?

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.

1) What is a prior authorization?

A prior authorization is an extra step that some insurance companies require before they decide if they want to pay for your medicine.

2) What medicines require a prior authorization?

I. Brand name medicines that have a generic 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.
II. Expensive medicines.
III. 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.
IV. Drugs used for cosmetic reasons. For example, Propecia®, which is prescribed to re-grow hair or to prevent hair loss.
V. Drugs prescribed to treat a non-life threatening medical condition. These drugs are usually not needed to maintain life. An example is erectile dysfunction drugs such as Cialis®.
VI. 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 any other medicines that would work in the patient.
VII. Drugs that are usually covered by the insurance company but are being used at a dose higher than “normal”.

3) 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.

4) 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:
√ Contact the doctor who prescribed the medicine and let them know that your medicine requires a prior authorization.
√ Ask your doctor how long it usually takes for them to contact the insurance company and fill out the appropriate forms.
√ Contact your insurance company and make sure there are not any additional steps you need to take. Sometimes an insurance company may want you to fill out some paperwork or sign some forms.
√ Allow the doctor’s office and insurance company enough time to complete their end of the process.
√ Check back with the pharmacy to see if the prior authorization was approved.
√ If your medicine is not approved, call your insurance company and find out why.

5) What are some of the reasons why a prior authorization may not be approved?

  • You did not give your insurance company, doctor, and pharmacist enough time to complete the needed steps.
  • Your insurance denied your prior authorization claim.
  • Your doctor’s office forgot to contact your insurance company.
  • 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 the wrong prior authorization code.

So you made it through the prior authorization process. It’s over, right? Wrong! The process may need to be renewed each year, or possibly every month depending on your insurance company. Be patient, but be persistent. Don’t give up.

© 2006 Consumer Health Information Corporation. All rights reserved.