Paul Sanchez
Getting insurance approval for medications can be a complex and time-consuming process. Many factors, including the medication's cost, brand, and usage guidelines, determine whether prior authorization from your insurance company is required. This process involves multiple steps and can take anywhere from a few days to a few weeks to complete. Understanding the requirements and starting the process early are crucial steps in obtaining insurance approval for your prescribed medication.
| Characteristics | Values |
|---|---|
| What is it called? | Prior authorization |
| Who does it involve? | Your physician, pharmacist, and insurance company |
| When is it required? | When your insurance company requires additional approval before covering certain prescriptions |
| Why is it required? | To ensure the medication is appropriate for your treatment and to make sure it is the most cost-effective option |
| How long does it take? | A few days to a few weeks |
| What happens if it is denied? | You and your provider will be notified, and you can contact the insurance company for more information |
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What You'll Learn
What is prior authorization?
Prior authorization is a process where your medical provider must get approval from your health insurance company before you can receive a certain medication, treatment, or service. This is to ensure that the medication is appropriate for your treatment and that it is the most cost-effective option. It is also a way for insurance companies to review and ensure that the requested medication, procedure, item, or service is necessary for your care.
Prior authorization is typically required for complex or expensive medications and treatments, or those that may have adverse health effects, possibly dangerous interactions, and/or risks for abuse or misuse. It is also often required for brand-name drugs that have a generic alternative available, high-cost medications, and medications with specific usage guidelines.
The prior authorization process can be time-consuming and frustrating for both patients and physicians. It may involve submitting a request and supporting documentation to the insurance company, which then reviews the request and makes a decision. This can take up to 30 days, and there is a chance that the request may be denied. If the request is approved, the approval is typically valid for a specific length of time, often 12 months.
If you think you may need prior authorization for a medication or treatment, it is important to start the process early by asking your healthcare provider. They can submit the request and any necessary supporting information to your insurance company. If your request is denied, you and your medical provider can appeal the decision.
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How to get insurance approval for brand-only medication
If you are filling an expensive brand-only medication, it is worth noting that insurance companies may require prior authorization before covering certain prescriptions. This is to ensure that the medication is appropriate for your treatment and that it is the most cost-effective option. When prior authorization is granted, it is typically for a specific length of time, after which you will need to request prior authorization again. If you don’t get approval, you may be responsible for the cost of the medication, but you can appeal the decision.
To get insurance approval for brand-only medication, you can start by asking your doctor to write "do not substitute", "dispense as written", or "brand medically necessary" on the prescription. This is because pharmacists may substitute generic medications for what your doctor prescribes, and some pharmacies even require their pharmacists to do so. Your doctor can prevent this by writing one of the aforementioned phrases on the prescription.
If your insurance company still does not approve the brand-only medication, you can ask for an exception. If that doesn't work, you can appeal the coverage decision. If your appeal is for a medication you haven't started taking yet, the insurer must complete the internal review within 30 days. If it's for a medication you've already been taking, the review must be completed within 60 days. In urgent situations, you can request an expedited appeal, in which a final decision must be made within 4 business days. If your insurance plan denies your appeal, try filing for an independent review through your state's insurance regulator as a last resort.
Additionally, you can look for any discount cards or patient assistance programs that can help you save on specific medications, particularly costly, brand-name ones that are often not covered by insurance. These programs can reduce out-of-pocket costs to $0 per month for people with and without insurance. You can typically find these programs on the websites of the drug manufacturers.
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What to do if your prior authorization gets denied
If your prior authorization request is denied, it is important to understand the reason for the denial. In some cases, the insurance reviewer may reach out for additional information or request a "peer-to-peer" review, where a medical physician from your insurance company will discuss the request with your physician or provider.
If your request is formally denied, you should partner with your physician's office and provide them with the reason for the denial. They may be able to submit additional information or evidence to support the request. This could include consult notes, test results, or other relevant details.
After gathering the necessary information, you and your physician can send a letter of appeal to your insurance company. This letter should include the prior authorization reference number, your diagnosis, and any relevant CPT codes associated with the procedure. It is important to note that appeals can be successful, with Forbes reporting that 82% of prior authorization denials that were appealed were ultimately fully or partially reversed.
To streamline the process and reduce the chances of denial, it is recommended to work closely with your physician and insurance provider. Additionally, utilizing a medical billing service or Electronic Prior Authorization (ePA) software can help organize your data and improve the efficiency of the authorization process.
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How long does prior authorization approval take?
The prior authorization process usually takes about two days. However, patients may wait days, weeks, or even months for a necessary test or medical procedure to be scheduled as physicians need to obtain authorization from an insurer. This is a cost-control practice used by insurance companies. Once approved, the prior authorization typically lasts for 12 months, after which you will need to request prior authorization again. The approval duration is determined by your insurance. If your insurance changes, a new prior authorization may be required.
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. You may also be able to speed up the process by speaking with your insurer directly and submitting an urgent request for a faster decision.
It is important to note that the prior authorization process can be unpredictable and time-consuming for physicians as well. They may have to submit multiple appeals and fill out extensive paperwork. In some cases, insurance companies may take their time to respond, causing delays in patients receiving their medications.
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What are the reasons for prior authorization being denied?
Prior authorization is a cost-control practice used by insurance companies to determine coverage and verify the clinical necessity of a drug. It is a process that can delay care, causing frustration for healthcare providers and patients. There are several reasons why prior authorization may be denied:
- Lack of Information or Clerical Errors: A request may be denied if it lacks sufficient information about why the medication or treatment is needed. Simple errors such as leaving fields blank, misspellings, or submitting the wrong billing code can also lead to a denial.
- Not Included in the Approved List of Medications: If a medication is not on the insurance company's approved list of covered drugs, the prior authorization request will likely be denied. This list can change throughout the year, making it challenging for providers to keep track of covered medications.
- Cost-Effectiveness: Prior authorization is often used to ensure that the medication is the most cost-effective option for treatment. If a lower-cost alternative is available, the insurance company may deny coverage for a more expensive brand-name drug, especially if a generic version is available.
- Medical Necessity: The insurance reviewer may deny a request if they determine that the treatment or medication is not medically necessary for the patient's condition.
- Out-of-Network Provider: Prior authorization may be denied if the patient's provider or servicing facility is out of network and not covered by the insurance plan.
- Adverse Health Effects: In some cases, prior authorization may be denied for drugs that have potential adverse health effects, dangerous interactions, or a high risk of abuse or misuse.
It is important to note that if a prior authorization request is denied, patients and their physicians have the option to appeal the decision and provide additional information to support the request.
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Frequently asked questions
Prior authorization is when an insurance plan asks for additional papers or information from the doctor or pharmacy before it agrees to pay for a medication or service. It is the insurance plan's way of making sure that your medication is needed and appropriate to treat your condition.
You can call your insurance provider directly and ask them. However, if your doctor hasn’t filled out a prior authorization request, you will likely find out at your pharmacy when you try to fill or pick up the prescription.
If your prior authorization request is denied, you and your provider will get notified about the denial. You or your provider can then contact the insurance company for more information. Your provider can try to send in more documentation for reconsideration of coverage or change the therapy. You can also try to appeal the request to your insurance company for coverage of your medication.
The prior authorization process can range from a few days to a few weeks. It depends on the urgency of getting the medication, the speed of the provider and insurance company's communication, and the complexity of completing all the required steps.
