Orlando Harmon
Getting a medication approved by your insurance company can be a frustrating process. It often involves a prior authorization process, which can take up to two days, and sometimes even longer. This is a cost-control tactic used by insurance companies to determine whether or not they will pay for certain medications. If your prescription requires prior authorization, your pharmacy will notify your healthcare provider, who will then provide the necessary information to your insurance company. If your request is urgent, you may be able to pay upfront at your pharmacy and submit a reimbursement claim after approval. If your insurance company denies your request, you have the right to appeal the decision and have it reviewed by an independent third party.
| Characteristics | Values |
|---|---|
| What is prior authorization? | A restriction put in place by insurance companies to determine whether or not they will pay for certain medicines. |
| When is prior authorization required? | When a medication has less expensive alternatives, is complex, or is brand-name with a generic alternative available. |
| Who can request prior authorization? | You or your medical provider can request prior authorization. |
| How long does prior authorization last? | Prior authorization only lasts for a set period of time, after which you will have to re-apply. |
| How long does it take to get approved? | The prior authorization process usually takes about 2 days, but you may be able to speed it up by speaking with your insurer directly or submitting an urgent request. |
| What if my prior authorization request is denied? | You can submit an appeal if you believe your prior authorization request was incorrectly denied. Appeals are most successful when your provider deems your treatment medically necessary. |
| What if my insurance company still won't pay for my prescription? | You have the right to appeal the decision and have it reviewed by an independent third party. |
| What if I can't get a refill? | You have the right to follow your insurance company's drug exceptions process to get a prescribed drug that's not normally covered by your health plan. |
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What You'll Learn
Check your insurer's website for a list of approved medications
When it comes to getting a medication approved by your insurance, it's important to check your insurer's website for a list of approved medications. This list is often referred to as a "formulary" or "prescription drug list". By reviewing this list, you can determine if your prescribed medication is covered by your insurance plan. The insurer's website should also provide information on the process for obtaining approval for medications that are not on the list.
Each insurance company maintains its own list of approved medications, and these lists can vary. The medications included in the formulary are typically selected based on their effectiveness, safety, and cost-effectiveness. Insurance companies negotiate with pharmaceutical manufacturers to obtain discounts on these medications, making them more affordable for insured individuals.
It's worth noting that formularies may be organized into different tiers, with medications in higher tiers having higher out-of-pocket costs. Additionally, formularies can change periodically as new medications become available or as insurance companies update their coverage policies. Therefore, it's important to regularly review the list to ensure that your medication remains covered.
If you cannot find your medication on the insurer's website, don't lose hope. You may still be able to get it covered through a process called prior authorization. This process involves your healthcare provider submitting a request to your insurance company, explaining why the specific medication is medically necessary for your treatment. Prior authorization is often required for complex treatments or prescriptions and can be time-consuming, so it's important to start the process early.
In some cases, if your medication is not on the approved list and prior authorization is not granted, you may have the right to appeal the decision. You can work with your healthcare provider to build a strong case for why the medication is necessary for your treatment. Additionally, if you are enrolled in a state-regulated health plan, you may be able to request an exception to get a prescription drug covered, overriding certain policies such as prior authorization or step therapy protocols.
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Contact your insurer directly to speed up the approval process
Contacting your insurer directly is a good way to speed up the approval process for your medication. It is important to begin the prior authorization process early, as it can take time to get approval. While the process usually takes about two days, it can sometimes take much longer.
You can start by calling your insurer or visiting their website to find out what is covered by your plan. Have your plan information available, as you will need it to review your coverage. You can find the number to call on your insurance card, the insurer's website, or the detailed plan description. You can also review any coverage materials that your plan has mailed to you.
If you need a medication that is not covered by your plan, you can ask your insurer about the exceptions process. This process allows you to request coverage for a prescription drug that is not normally covered by your health plan. Your doctor will need to confirm to your health plan that the medication is appropriate for your medical condition. For example, they may need to confirm that other covered drugs have not been or will not be as effective, or that an alternative drug has caused or is likely to cause harmful side effects.
If your request is urgent, you may be able to submit an urgent request for a faster decision. In some cases, your insurer must respond within one day. If you cannot wait for approval, you may be able to pay upfront at your pharmacy and submit a reimbursement claim after approval.
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Appeal the decision if your request is denied
If your request for medication coverage is denied, you have the right to appeal the decision and have it reviewed by an independent third party. There are two ways to appeal a health plan decision: an internal appeal and an external review.
Internal Appeal
If your claim is denied, you can ask your insurance company to conduct a full and fair internal appeal. They are required to review their decision and must speed up this process if your case is urgent. You can start the internal appeal process by calling your insurance provider and asking for more details about the denial and your appeal options. Your insurance agent can walk you through the specific steps of the internal appeal process, as each insurance company has its own process. Make sure to find out what forms you need to submit and how long you have to appeal the decision.
To support your internal appeal, you can ask your doctor to write a letter explaining that the medication was medically necessary or provide other supporting documents. You can also include original bills and documents related to the service, notes and dates from phone calls with your insurance company or doctor's office, and your policy documents, including your Evidence of Coverage or Summary of Benefits.
External Review
If your internal appeal is rejected, you can submit your case for an external review by an independent third party. This means that someone who doesn't work for your insurance company will conduct a full review and give you a final answer. You can find more information about your external review options in your Explanation of Benefits (EOB), along with contact details for the external reviewer.
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Ask your doctor to confirm the drug is appropriate for your condition
It is important to ask your doctor to confirm that the drug is appropriate for your condition. This is because insurance companies will often require prior authorization for certain drugs, and this confirmation from your doctor may be necessary to obtain approval.
Prior authorization is a tactic used by insurance companies to control costs. It is a restriction put in place to determine whether or not they will pay for certain medicines. Insurance companies will most likely require prior authorizations for brand-name drugs that have a generic alternative available, drugs intended for specific age groups or conditions, drugs used for cosmetic reasons, and drugs that are neither preventative nor used to treat life-threatening conditions. Additionally, drugs that are dosed higher than standard and may have adverse health effects or risks for abuse may also require prior authorization.
If your prescription requires prior authorization, your pharmacy will notify your healthcare provider, who will then provide the necessary information to your insurance company. Your insurer will then decide whether or not to cover your medication. This process usually takes about two days, and once approved, the prior authorization is valid for a defined period. If you are unable to wait for approval, you may be able to pay upfront at your pharmacy and submit a reimbursement claim if your authorization is approved later.
It is important to note that the prior authorization process can be unpredictable and frustrating for both patients and doctors. In some cases, insurance companies may take a long time to respond, and inappropriate rejections are common. Therefore, it is advisable to start the prior authorization process early and be prepared to submit an appeal if necessary.
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Request an exception to get a non-preferred drug covered
If your health insurance company is unwilling to pay for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party. You can also request an exception to get a non-preferred drug covered.
A tiering exception should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier. A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary or to request to have a utilization management requirement waived (e.g. step therapy, prior authorization, quantity limit) for a formulary drug.
To file a formulary exception, your doctor will need to send paperwork to your health plan indicating the reason that you can't take the preferred medications and must be prescribed one that is not currently on the formulary. There is typically specific paperwork that must be turned in as part of the exception process, so make sure to call your health plan and obtain copies of the correct forms. Some plans allow formulary exceptions to be submitted online, so check your health plan's website to see if you can file electronically.
Once the exception is filed, the plan should provide a decision within 72 hours. If your doctor feels that you not having the medication could put you in serious harm, an "urgent" or expedited request can be filed, and a decision would be made by your health plan within 24 hours. If your formulary exception is denied by your health plan, you may have the right to appeal and ask for a reconsideration.
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Frequently asked questions
Prior authorization is a requirement by insurance companies for some medications that may have less expensive alternatives. If your medication requires prior authorization, your pharmacy will notify your healthcare provider, who will then give the necessary information to your insurance company. Your insurer will then decide whether or not to cover your medication. You can also call your insurer directly to confirm if prior authorization is needed.
If your insurance company doesn't cover your medication, you can try generic alternatives or other less-costly options. You may also qualify for patient assistance and manufacturer copay programs that can help cover costs. If these options don't work, you can request an exception or appeal the coverage decision.
The prior authorization process usually takes about 2 days, but it can vary depending on the urgency of the medication, the complexity of the paperwork, and the speed of the insurance carrier's review. Once approved, the prior authorization typically lasts for 12 months, but this duration is determined solely by your insurance provider.
