The Insurance Nerd – Prescription Drug Pre-Authorizations

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Most of the time, if your doctor prescribes you a medication, the process goes fairly smoothly. Sometimes, however, you may arrive at the pharmacy to find out that your insurance refused the medication. What!? But, your doctor said you NEED that particular medication at that dosage, and what in the world is going on!

There are a few different reasons why medications can be denied, but one of the most common is because it’s a medication that requires prior authorization. That means that before you can fill your prescription, your doctor needs to file a pre-authorization form with your insurance company. Much like getting prior authorization for certain medical procedures, the doctor will be asked to submit documentation of medical findings indicating why that specific medication is necessary.

In the past few months, I have received several frantic calls and emails from clients and their employees because a pharmacy claim was denied. The first question that usually comes up is, “Can we file an appeal?” The fact is, in all of these cases what has been amiss is simply that the doctor did not apply for prior authorization. Once we go back and explain this to the clients and the doctors, the process moves mostly smoothly.

There are a few things to keep in mind about prior authorizations on prescriptions:

  • Some medications require pre-authorizations. This may include brand name versions of drugs that have generic versions available, or drugs that have comparable substitutes on the market. It may be that you need to try the other versions first; this is called step therapy.
  • It is the prescribing doctor’s responsibility to submit a request with supporting documentation. Your agent or HR personnel may be able to help facilitate this.
  • Pre-authorizations are only good for a specific dose and a specified length of time. If your dosage changes or you need to be on the medication longer than initially specified, your doctor will need to submit another pre-authorization request.

In general, if a claim of any kind is denied, it’s best for you to call the number on your insurance card and get the rationale directly from the company, so you understand what needs to be done and why you are in this stressful and confusing situation.