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Prior Authorization: What You Need to Know

by The GoodRx Pharmacist on October 25, 2013 at 4:50 pm

Have you ever walked into the pharmacy and been told that your prescription requires a prior authorization? But your doctor prescribed something for you, and you brought in your prescription, shouldn’t that be enough? What exactly is a prior authorization, and why can’t you just pick up your prescription? Here is what you need to know about the process of prior authorizations.

What exactly is a prior authorization?

It’s an approval from your insurance company, not your doctor. Prior authorization is a step put in place by insurance companies in order to decide whether or they will pay for certain medicines. It doesn’t affect cash payment for prescriptions, and it’s only required on those prescriptions when billed through insurance—so if you’re uninsured or if you decide to pay in cash, you won’t need to worry about getting prior authorization.

What types of prescriptions generally require prior authorization?

Insurance companies want to review prescriptions before paying for them in a variety of situations, including:

– Brand name drugs prescribed when a generic is available

– Drugs that are intended for certain age groups or conditions only

– Drugs used only for cosmetic reasons

– Drugs that are not preventative, or used to treat non-life threatening conditions

– Drugs that may have adverse health effects, including higher than standard doses, or possible interactions, abuse, or misuse

– Drugs that are not covered by your insurance but deemed medically necessary by your provider

In many cases, prior authorizations are intended to be a control to ensure drug use is appropriate and the most clinical and cost-effective therapy is being used.

What should you expect if you need a prior authorization?

In most cases, the pharmacy will notify your healthcare provider, who will provide the necessary information to the insurance company. The insurance company will then decide whether to accept or deny coverage on the medicine.

Since the process takes several steps, it may take some time before the pharmacy has a response. You can usually expect a delay of at least 1 to 2 days, although sometimes it can take longer. If approved, prior authorizations are only valid for a set amount of time and may require periodic re-approval.

What do you do if your prior authorization is denied?

If your prior authorization is denied, your insurance won’t cover the prescription. At this point, you may want to talk to your pharmacist and healthcare provider about alternatives that would be covered. You can also decide to pay out of pocket, and compare discount cards, cash prices, and assistance programs to determine what works best for you.

Some cases when your insurance may decide not to cover your prescription? Cosmetic medicines (such as Retin-A for acne in adults, Propecia for hair growth) or in non-essential medicines (Cialis or Viagra for erectile dysfunction).

Till next time,

The GoodRx Pharmacist

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