Heading over to the pharmacy is never a fun chore. After you’ve discussed treatments with your doctor, picked a medication you can both agree on, you’re forced to wait in line to pick it up. And, to pile it on, you may find out at the pharmacy that the medication you were prescribed wasn’t even pre-authorized by your insurance company! That means you might be stuck paying the full cost of the prescription.

At this point, you may be asking yourself what prior authorization for prescription drugs is and how you can get it. HealthMarkets has the answer.

What Does Prior Authorization Mean?

Prior authorization for prescription drugs is required when your insurance company asks your physician to get specific medications approved by the insurance company. Prior authorization must be provided before the insurance company will provide full (or any) coverage for those medications.

Why Do Insurance Companies Require Prior Authorization?

In short, health insurance companies pre-authorize medications in order to keep healthcare costs low. By ensuring that your medication is medically necessary, up-to-date, as economical as possible, and isn’t being duplicated, health insurance companies can afford to provide more expensive medications to those who truly need it.

What Kinds of Medications Warrant Prior Authorization?

There are several reasons a medication may require a prior authorization request. For example, the prescription may:

  • be a brand name medication that is available as a generic.
  • be expensive (as with psoriasis and rheumatoid arthritis medications).
  • be used for cosmetic reasons (as with hair growth and wrinkle treatments).
  • be used at higher doses than normal.
  • treat non-life threatening conditions.
  • not usually be covered by the insurance company, but is deemed medically necessary by the physician (who must also inform the insurance company that no other covered medications will be effective).

How Can You See If You’ll Need One?

There are several ways to find out if you’ll need to get prior authorization for a prescription drug from your insurance company. First and foremost, you could call your insurance provider directly and ask. Also, pharmacies (like Caremark) often create lists of prescriptions that will require some form of pre-authorization. However, if your doctor has not filled out a prior authorization request, you will most likely find out at your pharmacy when you try to fill or pick up the prescription.

How Does Prior Authorization Work?

How to Get Prior Authorization (after the fact):

  • Call your physician and ensure they have received a call from the pharmacy.
  • Ask the physician (or his staff) how long it will take them to fill out the necessary forms.
  • Call your insurance company and see if they need you to fill out any forms.
  • Check in with your pharmacy (after several days) to see if the prior authorization request was approved. If it wasn’t, you can see why.

Prior authorization works like this:

  • Step 1: Your pharmacy will contact if your doctor if he or she did not obtain prior authorization from the insurance company when prescribing a medication.
  • Step 2: The physician will contact the insurance company and submit a formal authorization request.
  • Step 3: Your insurance provider may have you fill out and sign some forms.
  • Step 4: The insurance company will alert the pharmacy once they have approved or denied the request.

How Long Does Prior Authorization Take?

Prior authorization can take days to process. Within a week, you can call your pharmacy to see if the prior authorization request was approved. If it wasn’t, you can call your insurance company to see why the authorization was delayed or denied..

HealthMarkets: Your Source for Health Insurance Information

Whether it’s deductibles or prior authorizations for prescription drugs, HealthMarkets wants you to understand the ins and outs of your coverage. By sharing as much as we can, we strive to save you money in the nooks and crannies you may never have even considered. To learn more, visit our resource center. Or, if you’re looking for coverage and want to speak to us directly, call us at (800) 429-5058.




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