A prior authorization is an extra step that some insurance companies require for certain medications. If your medication requires a prior authorization, it means the insurance company needs more information from the prescribing doctor before they can decide if they want to pay for 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.
You may contact your insurance at any time to find out why your medication requires a prior authorization, how long it will take and what you can expect to pay if the authorization is approved.
The prior authorization process may need to be renewed each year, or possibly every month depending on your insurance company.
What medicines require a prior authorization?
- Expensive medicines.
- 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 determined by the insurance company.
- Drugs used for cosmetic reasons. For example, Propecia, which is prescribed to re-grow hair or to prevent hair loss.
- Drugs prescribed to treat a non-life threatening medical condition. An example is erectile dysfunction drugs such as Cialis.
- Brand name medicines that have a generic available.
- 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 for the patient.
- Drugs that are usually covered by the insurance company but are being used at a dose higher than “normal”.
What should I do if my medicine needs a prior authorization
- 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 (usually a minimum of 3 business days once the doctor initiates 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.
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.