Haris Ashley
Getting a medication approved by insurance can be a challenging and lengthy process. It often involves navigating the complex world of prior authorization, where doctors and patients have to jump through hoops to get the necessary approval for specific medications or treatments. This process is designed to confirm the medical necessity of a prescribed drug and ensure it aligns with the insurer's criteria and cost-control measures. The approval process can be time-consuming and burdensome for both doctors and patients, requiring extensive paperwork, phone calls, and sometimes appeals. Understanding the steps involved, such as submitting forms, verifying insurance details, and knowing your plan's specific policies, can increase the chances of a timely and positive decision. This process can be made easier by working closely with your doctor and seeking help from patient advocates who can guide and coordinate the necessary steps.
How to get a medication approved by insurance
| Characteristics | Values |
|---|---|
| Prescription medication | Medication must be approved by the Food and Drug Administration (FDA) and prescribed by a health care professional. |
| In-network pharmacies | Some plans require the use of an in-network pharmacy to fill the prescription. |
| Prior authorization | Insurance companies may require prior authorization to confirm medical necessity before approving coverage. |
| Medically necessary | The medication must be deemed medically necessary and align with the insurance plan's coverage criteria. |
| Cost | High-cost medications often trigger a review to confirm they are being prescribed appropriately and to assess if a less costly alternative could be equally effective. |
| Generic drugs | If there is a generic equivalent or a more commonly prescribed treatment, insurers may require justification for choosing a brand-name or specialty drug. |
| Formulary | Medications on your plan's "formulary" (approved list) will usually be less expensive. |
| Drug exceptions | If a prescribed drug is not normally covered by your health plan, you have the right to follow your insurance company's drug exceptions process to request coverage. |
| Appeals | If your health insurance company won't pay for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party. |
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What You'll Learn
Understanding the process of prior authorization
The process of prior authorization is a cost-control practice that can delay care. It is a process that gives your health insurance company the chance to review how necessary a medical treatment or medication may be in treating your condition. Prior authorization is usually required if you need a complex treatment or prescription. Coverage will not happen without it.
The process typically resembles the following flow: First, a healthcare provider determines that a patient needs a specific procedure, test, medication, or device. The onus is on the provider to then check a health plan's policy rules or formulary to determine if a prior authorization is required for the prescribed course of treatment. If it is required, the provider will need to formally submit a prior authorization request form and sign it to attest that the information supporting the medical necessity claim is true and accurate. The provider must continue to follow up with the insurance company until there is a resolution to the prior authorization request — an approval, redirection, or denial. This part of the process is unstructured and often improvised, which can lead to significant wasted time and effort.
The prior authorization process is often complicated by a combination of factors, including the number of required steps, the participation of payers and providers, the lack of standards, and the manual review of requests and medical charts by clinicians. The time taken for prior authorization can vary from one day to a month, depending on the complexity of the request, the level of manual work involved, and the requirements stipulated by the payer. During this time, patients may experience declining adherence to medication and treatment due to postponements or additional steps.
If your health care provider is in-network, they will start the prior authorization process. If you don’t use a health care provider in your plan’s network, then you are responsible for obtaining the prior authorization. If you don’t obtain it, the treatment or medication might not be covered, or you may need to pay more out of pocket.
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Knowing if your medication is on the insurer's approved formulary
To find out if your medication is on your insurer's approved formulary, start by checking your insurance plan's website. Look for a tab related to medications, such as "find drugs" or "covered medications." If you know the name of your plan, you can search for its formulary. If you cannot find the formulary online, contact your insurer and request them to send you a copy via mail or email.
It is important to note that formularies can change at the start of each calendar year, so it is advisable to check the list before ordering your first refill of the year to ensure your drugs are still covered. Additionally, drug placements on the tiers may vary between insurance companies, so a drug listed as tier 1 by one company may be listed as tier 2 by another.
If your medication is not on the approved formulary, there are still options available. Your doctor can submit a formulary exception request on your behalf, especially if you have allergies or adverse reactions to the alternative medications on the formulary or if the formulary drugs may interact poorly with your other medications. If your exception request is approved, your insurer must inform you of the cost-sharing amount. You also have the right to appeal the decision if your request is denied.
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Working with your doctor to submit forms and verify insurance details
If your doctor didn't contact your insurance company when prescribing medication, your pharmacy will do so. They will inform the physician that the insurance company requires prior authorization. The physician or their staff will then contact the insurance company, fill out forms, and submit a formal authorization request. This process can be lengthy and frustrating for doctors, who often have to fill out a lot of paperwork and make many phone calls to get permission for certain medications.
You can ask your physician or their staff how long this process usually takes. Your insurance provider may also require you to fill out and sign forms. It is a good idea to call your insurance company and make sure there is nothing else they need before they review and approve the request.
It is important to begin the prior authorization process early. You can ask your healthcare provider if a prescription or treatment will require prior authorization so they can start the process immediately. You can also call your insurance provider directly and ask them. If your doctor hasn't filled out a prior authorization request, you may only find out at your pharmacy when you try to fill or pick up the prescription.
If your insurance company denies the request, you have the right to appeal the decision and have it reviewed by an independent third party. You can also ask your insurance company why the authorization was denied or delayed.
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Knowing your rights to appeal a rejected request
If your health insurance company refuses to pay for your prescription, you have the right to appeal the decision. There are two ways to appeal a health plan decision: an internal appeal and an external appeal.
Internal Appeal
If your claim is denied or your health insurance coverage is cancelled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process. After the internal review, your insurance company will inform you of its decision. If the insurance company overturns the initial decision, your care will be covered.
External Appeal
If the insurance company upholds the decision, you can opt for an external appeal. This is when you take your appeal to an independent third party for review. This means that the insurance company no longer gets the final say over whether to pay a claim. Usually, you will have four months from the denial of your internal appeal to ask for an external appeal.
General Tips for Appealing a Rejected Request
- You must follow your plan's appeal process. Check your plan's website or call customer service for detailed instructions on how to file an appeal and how to complete specific forms.
- Ask if there is a deadline for filing an appeal.
- Inform your doctor or the hospital that you are filing an appeal. Request that they hold off on sending you bills until you hear back from your insurance company.
- Keep records of all communication with your insurance company. Write down the name of the person you talked to, the date, and what was decided.
- If you don't know why your claim was denied, call your insurance company to ask.
- If you think you may want to appeal the decision, ask the representative to explain the process or send you a description of how to appeal.
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Getting help from patient advocates to ease the process
Getting a medication approved by insurance can be a challenging and time-consuming process. Prior authorization is often required for certain medications, and this can involve a lot of paperwork, phone calls, and back and forth with insurance companies. This is where a patient advocate can step in and help ease the process.
A patient advocate is a person who helps you navigate the healthcare system and ensures you get the care you need. They can be especially beneficial for older adults or those with complex health concerns. Patient advocates can be found through advocacy groups, hospitals, or online resources. Some insurance providers even offer advocate services. It is worth calling your insurance company to see if this is an option for you.
There are also state-specific resources available, such as the Patient Advocacy Program in Pennsylvania, which helps patients who are prescribed controlled substances. This program involves the collaboration of multiple agencies, including the Pennsylvania Insurance Department, to help patients understand their options and address barriers to care.
When working with a patient advocate, it is important to provide them with detailed information about your medical history and any medications you are currently taking. You may also want to give them access to your electronic health records and your healthcare team's contact information. A good patient advocate will be organized, assertive, and comfortable asking questions. They can help ensure that you understand your doctor's instructions and can also assist with issues such as medication management and safety.
By enlisting the help of a patient advocate, you can have additional support when dealing with insurance companies and navigating the often complex world of healthcare. This can lead to better outcomes and a more positive experience overall.
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Frequently asked questions
Prior authorization is a requirement from an insurance company that your doctor obtains approval before prescribing a specific medication or treatment. This is done to confirm that the prescribed drug is medically necessary and aligns with the insurance plan's coverage criteria.
If your health insurance company won't pay for your prescription, you have the right to appeal the decision and have it reviewed by an independent third party. You can also follow your insurance company's drug exceptions process to get a prescribed drug that's not normally covered by your health plan.
Here are some tips to get prior authorization:
- Start the prior authorization process early.
- Discuss your treatment plan and any specific medications your provider recommends. Ask if the medication might require prior authorization and whether there are alternatives.
- Make sure your doctor is aware of your insurance coverage and any formulary limitations.
- Ask for details about the documentation required to request approval, including diagnosis codes, previous treatments, or explanations of why other medications aren't suitable.
