Prior authorization, or PA, is a requirement for certain medications and treatments. Before you can receive the care you need, your insurance company may need to grant approval first. Sometimes the process is handled before you get to the pharmacy, while other times you may be told you have to wait for your insurance provider to allow you to get the prescription through them. Let’s take a closer look at everything you need to know about prior authorization for medications.
What is Prior Authorization for Medication?
So, what is a prior authorization? Before a physician is able to administer certain medical procedures, devices, or specific medications, they may need to follow the process to get approval from your insurance company. Prior authorization has to be requested before the request for your insurance to cover all or a portion of your treatment. Your physician’s request may even be denied.
Why a Prior Authorization is Required by Insurance
According to health insurance companies, prior authorization is required for some treatments, medications, procedures, and medical devices to keep the cost of healthcare lower.
Medications That Need PA
Prior authorization is a requirement for several different medications. The request may be necessary for a number of reasons, including:
- The medication is expensive (such as rheumatoid arthritis and psoriasis medications)
- There is a cheaper generic version available and the physician is requesting the brand name
- Used to treat conditions that are non-life threatening
- Used at doses higher than normally recommended
- Cosmetic use (such as wrinkle treatments and hair growth)
- Your physician deemed it medically necessary (if this is the case, they need to inform the insurance company that other medications that are covered will not be effective forms of treatment for you)
How to Tell if You Need Prior Authorization
Finding out if your insurance company requires prior authorization is easy. Calling your insurance company and asking them directly is a good way to go. Otherwise, your pharmacy will inform you if prior authorization has been requested by your doctor when you go to fill or pick up the prescription. If it has not been approved, they will charge you the full amount.
How Prior Authorization Works
When your doctor requests a prescription for you, they should contact your insurance for prior authorization. If they did not, however, your pharmacy will contact the doctor to let them know the authorization is required. Once they are aware that approval needs to be requested, your doctor or a member of their staff will reach out to your insurance to get the forms filled out and submitted. This can take a while, depending on your insurance company.
In addition to the paperwork your doctors’ office submits on your behalf, your insurance provider may also require you to fill out some forms as well. You should call them to see if there is anything you need to do on your end before they review and approve your request. Once the insurance company has made its decision, it will contact you, your doctor, or your pharmacy about whether the request was approved or denied.
How Long Does it Take?
In most situations, prior authorization takes a few days to process. The specific time frame depends on what type of medication or procedure your physician has requested, along with the insurance company you have. If you haven’t heard anything by a week after your initial discussion with your doctor, you can contact the pharmacy to see if the request was approved. If your submission was not approved, the next step is to contact your insurance company directly to find out why the request was denied or delayed.