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Medication Prior Authorization

Understanding Prior-Authorization for Prescriptions

All insurance companies have a prescription drug formulary and each individual plans’ formulary is different. A prescription drug formulary consists of the medications the plan covers. This formulary is based on the negotiated price per pill the plan has with the drug manufacturer. These medications are tiered based on cost. Generic drugs are the lowest tier because they are the least expensive. More expensive brand drugs will be the highest tier and there is usually a tier in between.  

Both the provider and patient sign a contract with the insurance company stating they will try to follow the insurance company’s formularies whenever possible. We try to provide you the most effective and cost effective prescriptions but we cannot always keep up with the numerous formularies and formulary changes for all the insurance companies we participate with. We advise you to contact your insurance company to review and understand your prescription drug plan coverage and limitations at least once a year. Check with your insurance plan to see what rules you will need to follow. You should be able to get a list of drugs in each tier of copayment and those that are non-formulary.

Some medications you are currently taking or new medications prescribed may require a prior authorization from your insurance company.  This means that the medication is not on your insurance company’s formulary. Drugs are made non-formulary mostly based on cost. If the cost per pill falls outside of what your insurance company deems acceptable then it is not covered. Insurance companies have to offer a way for medications that are non-formulary to be approved if medically necessary. Each non-formulary drug has a different set of criteria that has to be met in order for the insurance company to approve the higher cost medication. Your provider has no control over the criteria as it set by your insurance company. If the patient meets the insurance company’s criteria then the medication may be approved. If the patient does not meet the criteria then the insurance company may deny payment for the medication.

The prior authorization process is a cost saving mechanism put in place to save your insurance company money. Your insurance company understands the time it takes and burden it is on providers. The goal is to deter providers from prescribing costly medications by adding a time consuming step. Many insurance companies and pharmacies will claim “All your provider has to do is call this number to get your medication authorized.” The process is not that simple.

The prior authorization process requires the provider to answer a set of questions to determine if the patient meets the criteria they put in place. The questions can range from 3-15 questions depending upon the drug. Each insurance plan will have different forms and different criteria. Your insurance plan may require you to try alternative medications prior to approving more expensive medications. They often require written documentation that you have had an “adequate” trial of alternative medications or have a severe allergy or side effect. Some medications may not be covered at all depending on your drug plan coverage.

The prior authorization questions can be answered either via phone or by completing the questions on paper. The amount of time it takes to complete a prior authorization over the phone ranges from 20-45 minutes depending on the insurance company and their staffing. Completing the paperwork is more efficient but usually requires obtaining additional information from the patient. We only complete prior authorizations on paper in this office.

We understand that your plan may not cover a medication that you need.  We have come up with a process that is the most effective and efficient way to get the medication. Please understand that there are no exceptions to this process other than in cases of a medical emergency.

If you are told by the pharmacist that you need prior authorization please:

  1. Contact your drug benefit plan to get the forms you will need. You may be able to get the forms from your plan’s website however many plans will have to send them since the form is based on the specific medication in question. If you have any problems initiating the process please contact our office.
  2. Once you get the form review to see if you meet all the criteria for coverage.
  3. If you do meet the criteria, you can make an appointment to complete the paperwork.  Or you can get the form to us and pay the administrative fee for the completion of paperwork. This fee is based on the number of pages required to complete.  
  4. If you do not meet the criteria set out by your insurance plan they may not cover the medication.

We realize that this may be perceived as a significant inconvenience for you. Hopefully this information will help you understand the process. We appreciate your business and let us know if you have any questions.


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