What Is Prior Authorization? Why Do I Need One for My Prescription?

what is prior authorization

Your insurance company may ask for prior authorization before agreeing to cover the cost of certain medications. Understanding how prior authorization works and how to request it can help you to reduce delays in receiving your medication.

What is Prior Authorization?

Prior authorization is a process used to determine if your insurance company will cover a prescribed procedure, service, or medication. To authorize certain prescriptions, your insurance company will request that your prescribing doctor provide more information about your medical needs. This information helps determine if your insurance company will provide coverage for the cost of your medication.

In most cases, your pharmacist will tell you if you need prior authorization when you fill your prescription. Without prior authorization, you will be required to pay the full cost of the medication or treatment.

When Is Prior Authorization Required?

Insurance companies need additional information about certain prescriptions before deciding whether or not they are medically necessary – which means they should cover the cost. Prescriptions that typically require prior authorization include:

 

  • Brand name medicines with generic options available.

Your insurance company may ask why a brand name medication is being prescribed instead of an available generic option. Generics are typically less expensive, although they contain the same active ingredients, if not the exact formula, of their brand name counterparts.

 

  • Cosmetic drugs.

Your insurance company may request more information on the necessity of cosmetic drugs, such as hair loss medications or hormone therapy. Most cosmetic drugs are deemed medically unnecessary, but they are sometimes used in drug-treatment therapies that are covered by insurance.

 

  • Drugs with age limits.

If you are prescribed a drug that is normally aimed at a different age group, such as acne medication for teens or arthritis medication, your insurance company may require prior authorization.

Insurance companies want to rule out the possibility that you are collecting medication for people not covered by your insurance—like extended family, neighbors, or friends.

 

  • Higher dosages of drugs that are typically covered.

If you are being prescribed a higher dosage of a drug, additional information may be required to ensure that a possibly fatal mistake has not been made. This protects your health and the liability of your pharmacy and insurance company in case of an overdose.

Prior authorization, in this case, is also a precautionary measure against abuse of controlled substances like hydrocodone and ephedrine.

 

  • Drugs that are medically necessary, but are not usually covered by the insurance company.

If a medication that is not usually prescribed as treatment improves your particular condition, your doctor may have to offer a medical explanation to your insurance company to have the medication covered.

For example, if you are allergic to a medication known to effectively treat an illness, your doctor will have to justify the use of a non-traditional medication.

 

  • Medications for non-life threatening conditions.

Conditions that are not life threatening or damaging to your health—such as impotence—may require medication that needs to be explained to your insurance company. You may have to prove that your psychological or physical health are being impacted indirectly in order to have the medication covered.

My Insurance Company Requested Prior Authorization, Now What?

Some pharmacies require the patient to do the legwork on prior authorizations. Smith Caldwell Drug will take care of that for you. Our pharmacists and staff attempt to have this process done before you even know that it is necessary.

Sometimes the prior authorization process can be lengthy and could possibly result in a delay, but Smith Caldwell will attempt to have it completed within 24 hours.

If your prior authorization is approved, you will be able to pick up your prescription with your usual co-pay. If your authorization is not approved, contact your insurance company to find out why. With this information, you can contact your doctor to discuss other possible treatment options.

It is important to note that obtaining prior authorization may be required more than once. Your insurance company may require it again annually, or even monthly.

If you have any questions about your prescriptions, or would like to learn more about prior authorization, contact Smith-Caldwell Drug Store at 501-392-5470 to speak with one of our certified pharmacists.

*Image provided by Gatis Gribusts on Flickr.