Here’s why your pharmacy may ask for one.
If your doctor has prescribed you an expensive brand-name medication, the pharmacist may tell you that they need prior authorization from your health plan in order to fill the prescription. But what exactly does this mean, and what is your role in this process?
Prior authorization, sometimes called preauthorization, is a preapproval from your healthcare plan to cover a prescription medication or procedure. It’s a way for health insurance companies to control their costs and also ensure a medication or service is necessary. Your health plan, for instance, may require prior authorization for a brand-name medication your doctor is prescribing if there is a cheaper generic version available. Other medications or services that might require prior authorization can include drug types that are commonly abused, drugs used for cosmetic purposes or out-of-network care.
Who submits the prior authorization request? Do I need to do anything?
Often, your doctor will know which medications or services need prior authorization, but this is not always the case. If your doctor thinks prior authorization will be necessary, they will submit a medication or service request to the health insurance company on your behalf.
Sometimes, however, your doctor may not realize prior authorization was needed, and though you have the prescription, the pharmacist will inform you it cannot be filled unless they receive approval from your plan. In this case, you should call or message your doctor, who will submit the request to your health plan. In some health plans, the patient can send a prior authorization form themselves without the doctor, explains the Patient Advocate Foundation. No matter which route, your health plan will review the request and inform you of the decision. This process can sometimes take several days. According to Cigna, your health insurance company will typically approve or reject your request within five to 10 business days of receiving it.
What if my prior authorization request is rejected or I didn’t know I needed it?
If you want to forgo insurance coverage altogether and pay the full price for your medication or service, you won’t need to worry about obtaining prior authorization at all.
Unfortunately, submitting a request for prior authorization to your health plan is not a guarantee. The insurance company can reject the request, in which case you can submit an appeal for insurance to cover it with a doctor’s note explaining why it’s medically necessary. In some cases, for instance, a patient may not absorb the equivalent generic version as effectively as a brand-name pill because of differences in how they are made.
If your appeal doesn’t work, there are still options to save money: You can purchase a 90-day supply, for example, which can be cheaper than a 30-day supply. However, your doctor will need to write a new prescription for the 90-day duration. You can also compare pharmacy prices online and find coupons to lower the cost.
In the case of medical services in which you didn’t realize you needed prior authorization, you can appeal to the insurance company or ask the medical facility if they’re willing to negotiate on the bill.
Remember: Even if your prior authorization request is rejected, there are ways to dispute it or find discounts for the medications or services you need.