Have you ever gotten to your pharmacy to pick up a new medication only to be told that your insurance company is requiring a prior authorization, also known as a "PA"? If not, you are in the minority. These days, almost all brand name or expensive medications require a prior authorization. A prior authorization means the insurance company requires documentation from the prescriber showing why they are not prescribing a less expensive alternative medication.
The process is as follows:
- The pharmacy receives the prescription and attempts to adjudicate it. Adjudicating is the process of contacting your insurance company to determine whether the claim for the medication will be paid or denied.
- In the case of a prior authorization, this means the insurance company rejects the claim saying it requires a prior authorization.
- The pharmacy attempts to contact the prescriber to let him or her know the medication requires a prior authorization.
- Once the prescriber's office is aware of the need for a prior authorization they provide the necessary documentation to the insurance company.
- The insurance company either denies or approves the prior authorization.
- If the prior authorization is approved, the prescription can be filled. If not, your health care provider will need to decide whether or not to prescribe an alternative medication.
This process should only take between a few hours to a couple days to complete; however there are times that it can be delayed. Here are a few things that cause delays in Prior Authorizations:
- The health care provider's office is not aware of the prior authorization requirement because the fax was not received because the pharmacy had the wrong fax number or someone at the office accidentally threw it away with the 500 other faxes they got that day.
- The provider's office got the prior authorization approved by the insurance company, but the pharmacy was not alerted that it was approved.
- The provider prescribed an alternative medication, but you have not been informed.
The best way to avoid a long wait for your medication you have to take matters into your own hands. Every insurance company has a Prior Authorization Department. There will be a number to call on your insurance card. Once you get to that department, this is what you do:
- Ask to verify that a prior authorization has been initiated for the medication in question.
- If it has not been initiated it is likely your health care provider is not even aware one is required, so call your provider's office and let them know.
- If it has been initiated and not yet approved then you have to wait for approval. Once initiated you should have an answer within a day or two.
- If it has been approved already, the pharmacy has probably not been notified. Call your pharmacy and let them know you spoke with the insurance company and they said you medication was approved and ask them to reprocess the medication.
- If it has been denied, call the provider's office and ask if they plan to appeal the denial and if not, ask what alternative medication they plan to prescribe.
Remember you are the customer here. Your health care provider, your insurance company, and your pharmacy should all be working to keep your business, so don't be afraid to take matters into your own hands if you find things are not being taken care of in a timely fashion.
At Equiscript, you are assigned a Patient Care Advocate who can help you work through Prior Authorizations and other issues that may impact getting the medications you need when you need them. We are here to help at 877-303-8033.
Sean Dunleavy, Patient Sales Representative