Person holding a box of prescription drugs

Coordinating getting your prescription from a doctor and figuring out what you will owe to according your insurance plan can be frustrating enough. Now add on top of that, being informed that your prescription requires a prior authorization before it can be filled. If your doctor prescribed you a medication, and you then brought it into the pharmacy to be filled, shouldn’t that be sufficient? You may be wondering what a prior authorization even is. We will break it down in this article, so you know everything you need regarding the process of prior authorizations.

What is a Prior Authorization?

The reason why it is not always sufficient for a doctor to simply prescribe a medication for you to then be able to fill it is because authorizations do not come from the doctor. Rather, they are an approval of coverage from your insurance company. Typically, insurance companies will mandate prior authorizations for certain medications when they decide whether or not they will pay for those specific medications in the first place. It is also important  to note that prior authorizations only apply to prescriptions that will be billed through your insurance – so you if are uninsured or decide it would better to pay out of pocket, you won’t have to worry about getting prior authorization. If it is required, you will need to make sure that you have acquired prior authorization for a medication before the insurance company will then provide you coverage for it.

Why do Insurance Companies Require Prior Authorization?

Requiring prior authorizations for certain medications helps maintain lower healthcare costs —and we all know how exorbitant health care costs can unfortunately be at times. Essentially, prior authorizations help insurance companies better regulate the cost and transmission of prescription medications, helping to verify that your medication is medically necessary for you as well as up-to-date, etc., — which helps ensure that you and others for who it is deemed medically necessary for, get the medication they truly need.

What are the Types of Prescriptions that Require Prior Authorizations?

Let’s explore the typical medications that require prior authorizations from insurance companies:

  • Brand-name drugs that have generic versions available on the market
  • Drugs restricted to specific age groups or those with specific conditions
  • Drugs used for cosmetic purposes
  • Drugs that are used to treat non-life-threatening conditions or are preventative
  • Drugs with high risks associated with their use including potentially dangerous side-effects or interactions, as well as risks for abuse or misuse
  • Drugs that aren’t typically covered by the insurance company but are deemed medically necessary by the physician.

How Do You Find Out if You Will Need Prior Authorization for a Drug?

This will depend upon the requirements of your particular insurance plan. if you want to verify whether or not you will need authorizations for a medication, you can simply look up your insurance plan to determine what services require prior authorizations according to your plan.

What Exactly Does the Authorizations Process Entail?

1) Typically, your healthcare provider will submit a request for pre-approval to your insurance company.

2) The request will then go into a period of review which typically takes up to two weeks.

3) After the request has been reviewed and approved, only some types of patients will be informed of the approval. These include Medicare members, out of network members, as well as those who had previously been denied and are now approved. If your situation does not apply to these particular criteria, you would have to call your doctor’s office or customer service at your healthcare provider to determine whether or not the request for authorization has been approved.