Prior Authorization: What to Do When You Can’t Wait for Prescription Coverage

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Tori Marsh
Tori Marsh, MPH, is on the Research Team at GoodRx, and is the resident expert on drug pricing and savings.
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Amid news of the White House’s new plan to curb high drug prices, a tragic story from 2009 has resurfaced of a woman who died after being denied coverage for her life-saving epilepsy medication. Even more upsetting is that this tragedy was due to a prior authorization, an insurance restriction that thousands of Americans deal with daily.

Back in June, 2009, Yarushka Rivera’s family went to Walgreens to fill the anti-seizure medication Topamax, only to find out that their insurance would not cover the medication without proper authorization. The pharmacy told the family that without insurance, they would need to pay $399.99 out of pocket or wait for the pharmacist to contact the doctor for a pre-authorization form. Since the family could not afford $399.99, they opted to wait. According to the family, the doctor was never contacted, and Rivera died days later from a seizure without her medication at just 19 years old.

The tragedy only gets worse when you dig into the lifesaving anti-seizure drug, Topamax. In March, just two months before Rivera was denied coverage, the FDA officially approved topiramate, the cheaper generic alternative to Topamax, but it was probably still too new to be on pharmacy shelves when Rivera needed it. That left Rivera’s family to pay out of pocket or fight with their insurer.

Rivera’s family ran into an insurance restriction known as a prior authorization, where plans require confirmation from a doctor that a drug is medically necessary before they approve coverage. This process can typically take at least two days, and not all patients will get their medication covered in the end.

While we can’t say definitively that waiting for the prior authorization directly led to Rivera’s death, it’s important for patients to stay informed about insurance hurdles they may encounter to avoid tragedies like this in the future.

What is Prior Authorization?

Drugs that Need Prior Authorization

Insurance companies will most likely require prior authorizations for the following drugs:

In many cases, prior authorizations are intended to ensure drug use is appropriate and the most cost-effective therapy is being used. If you think your drug may require a prior authorization, call your insurer directly to confirm.

The Prior Authorization Process 

If your prescription requires a prior authorization, the pharmacy will notify your healthcare provider, who will provide the necessary information to your insurance company. Your insurer will then decide whether or not to cover your medicine, and you should hear back from your pharmacist about their decision within two days. Remember, if you are approved, a prior authorization only lasts for a set period of time, and you will likely have to re-apply again for future fills.

What Do I Do If My Prior Authorization is Denied?

Unfortunately, your insurer can deny you prior authorization, and you may be left on the hook for the full out-of-pocket price of your drug.

If you believe that your prior authorization was incorrectly denied, submit an appeal. Appeals are the most successful when your doctor deems your treatment is medically necessary or there was a clerical error leading to your coverage denial. One of the best ways to build your appeal case is to get your doctor’s input. Ask them about any backup documentation or medical notes that could help you prove your prescription is medically necessary.

If that doesn’t work, your doctor may still be able to help you. Some tricks to save include: getting a prescription for a higher-dose pill (which you can cut half to save on cost), filling a 90-day supply (which can be cheaper than a 30-day supply), or getting free samples. Additionally, if you are filling an expensive brand-only medication, look for any discount cards or patient assistance programs that can help you save. And don’t forget to shop around! In Rivera’s case, GoodRx could have saved her up to 15% on brand name Topamax with a GoodRx coupon. If you still can’t afford your medication, talk to your doctor or pharmacist about alternatives that may be more affordable.

Pro Tip: If you need your medication urgently, some pharmacies may let you purchase your prescription with a credit card as you wait for prior authorization and reimburse you if your authorization is approved within a week. While you are taking a risk, if you received prior authorization for the same drug in the past, it’s likely it will be approved again.

Drugs featured in this story

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