Jane Dotson
Getting medication approved by insurance can be a challenging and time-consuming process. The process, known as prior authorization, is a cost-control measure used by insurance companies to ensure patients use the right drugs and keep expenses low. It requires doctors to fill out extensive paperwork and make phone calls to get permission for specific medications or treatments. While prior authorization can cause delays in patients receiving their medication, there are ways to improve the process, such as utilizing electronic systems and improving communication between healthcare providers, pharmacies, and insurers. This article will explore the steps patients and healthcare providers can take to get medication approved by insurance, including understanding the requirements, gathering necessary documentation, and navigating the appeals process if the initial request is denied.
| Characteristics | Values |
|---|---|
| Who is responsible for obtaining prior authorization? | The doctor's office or the patient if the healthcare provider is not in the plan's network |
| What is the process for prior authorization? | The healthcare provider issues an order for medication, then files a prior approval inquiry with the insurance company |
| What is the average time for approval? | 1-3 days for normal requests, 1 day for emergency requests, a few days to over a week for complicated situations, and weeks for appeals |
| What happens if the insurance company denies the request? | The patient and their medical provider can appeal the decision and have it reviewed by an independent third party |
| What happens if the patient's pharmacy is not in-network? | The prescription may not be covered, or reimbursement may be limited by the plan's copayment, coinsurance, or deductible requirements |
| What if the patient can't get a refill? | The patient has the right to follow the insurance company's drug exceptions process to get a prescribed drug that's not normally covered by their health plan |
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What You'll Learn
- Prior authorization: Doctors must get approval from insurance for certain medications
- Approved list: Medications on the insurance plan's list are usually less expensive
- One-time refill: Some insurance companies provide a one-time refill for medication
- Appeals process: If insurance denies a request, patients can appeal the decision
- In-network pharmacies: Using an in-network pharmacy may be required for coverage
Prior authorization: Doctors must get approval from insurance for certain medications
Prior authorization is a cost-control practice used by insurance companies to determine whether or not they will pay for certain medications. This process was initially used for brand-new, expensive medications that had just entered the market, but it has since expanded to include a much broader variety of medications.
When a patient goes to the pharmacy to fill a prescription, they are sometimes informed that their insurance company won't cover the medication unless a physician obtains prior authorization. This can result in patients having to wait for extended periods before receiving the necessary medication or treatment.
Doctors must complete a significant amount of paperwork and make numerous phone calls to obtain prior authorization for specific medications or treatments. This process can be frustrating for both physicians and patients due to its opacity and unpredictability. Oftentimes, doctors are unaware of whether a particular treatment will be covered by insurance until the patient arrives at the pharmacy.
To speed up the prior authorization process, patients can speak directly with their insurer or submit an urgent request. Some pharmacies may allow patients to purchase their prescription with a credit card while waiting for prior authorization, reimbursing them if approval is granted within a specified time frame. Additionally, patients have the right to appeal the insurance company's decision and have it reviewed by an independent third party.
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![Drug coverage under national health insurance : Proceedings of the national conference, October 5-7, 1977 Editors : Milton Silverman and Mia Lydecker. 1978 [Leather Bound]](https://m.media-amazon.com/images/I/61IX47b4r9L._AC_UY218_.jpg)
Approved list: Medications on the insurance plan's list are usually less expensive
When it comes to prescription medications, health insurance plans typically cover a portion of the expenses. However, the amount of coverage provided can vary depending on the specific plan and the type of medications required. Some medications may be fully covered by your plan, while others may require a copayment or coinsurance. It's important to understand that not all health plans cover all prescription drugs, and purchasing medications not included in your plan can result in significantly higher out-of-pocket costs.
To ensure you're getting the most out of your insurance plan and minimizing your expenses, it's crucial to review the approved list of medications, also known as the "formulary." Medications included in the formulary are typically less expensive for you as they are covered, at least partially, by your insurance plan. This list can usually be found on your insurer's website or by calling them directly. Additionally, your Summary of Benefits and Coverage, accessible through your insurance company or your Marketplace account, can provide valuable information about covered medications.
It's worth noting that formularies may include both generic and brand-name medications. Generic versions of brand-name drugs can sometimes be cheaper, even without insurance. However, in most cases, insurance plans offer some level of coverage for prescription drugs, making them more affordable. Prior authorization, a cost-control practice, may be required by insurance companies for certain medications, particularly newer and more expensive ones. This process involves physicians obtaining approval from the insurer before patients can fill their prescriptions.
If you require a medication that is not on your plan's formulary, you have the option to follow your insurance company's drug exceptions process. This process allows you to obtain a prescribed drug that is not normally covered by your health plan. To do so, your doctor must confirm that the medication is appropriate for your medical condition and that other covered drugs or alternatives are ineffective or harmful. During the exceptions process, your insurance plan may provide temporary access to the requested drug until a final decision is made.
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One-time refill: Some insurance companies provide a one-time refill for medication
When it comes to medication, insurance companies have their own regulations, and prescription refill rules vary between insurance plans. Some insurance companies provide a one-time refill for medication after initial enrolment. This one-time refill can be useful if you need to discuss next steps with your doctor, or if you are waiting for an appointment to get a new prescription. It is worth asking your insurance company if they offer this option.
If your insurance company does not offer a one-time refill, you can follow their drug exceptions process to get a prescribed drug that is not usually covered by your health plan. Each insurance company will have its own process, so it is important to contact them for more information. To get your drug covered through the exceptions process, your doctor must confirm to your health plan that the drug is appropriate for your medical condition. They will also need to confirm that other drugs covered by the plan are not effective or will not be effective for your condition.
It is important to note that insurance companies have regulations about prescription refills, and these vary depending on the type of medication. For example, controlled substances have stricter laws and policies, and there is often a waiting period for refills to reduce the chance of misuse. This is known as the "28-day prescription rule", where there needs to be a minimum of 28 days between refills of 30-day prescriptions. Some insurance companies place a limit on the number of units of a drug that you can receive in a period, and if a doctor prescribes more than this limit, your insurance company may not provide coverage for the additional units unless a quantity limit exception is approved.
If your insurance company tells you it is "too soon" to refill your prescription, your pharmacist or healthcare provider may be able to help you access your necessary medications. In an emergency, a pharmacist can often authorise a one-time refill of a maintenance medication if a healthcare provider cannot be reached. This is called an "emergency prescription refill". However, the amount and type of medication that can be provided varies between states, and not all states allow for emergency refills of controlled substances.
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Appeals process: If insurance denies a request, patients can appeal the decision
If your health insurance company denies coverage for your medication, you have the right to appeal the decision and request a review by a third party. This process can be time-consuming, but it is often successful, with over 50% of appeals for denials ultimately being approved.
The first step in the appeals process is to understand why your claim was denied. Your insurance company is required to notify you of the denial and provide an explanation, typically in a document called Explanation of Benefits (EOB). Knowing the reason for the denial will help you address it effectively in the appeals process.
The appeals process typically has three levels:
- First-Level Appeal: Contact your insurance company and request that they reconsider the denial. You or your doctor may need to provide additional information or documentation to support your case. Your doctor may also request a "peer-to-peer insurance review" with the medical reviewer of the insurance plan to challenge the decision.
- Second-Level Appeal: If the first appeal is unsuccessful, the claim is reviewed by a medical director at your insurance company who was not involved in the initial decision. This step aims to prove that your request should be accepted within the coverage guidelines.
- Independent External Review: If the internal appeals are not successful, you can request an external review by an independent third party. This involves an independent reviewer from the insurance company and a doctor with the same specialty as your doctor assessing your appeal to determine coverage approval or denial.
It is important to note that the specific appeals process may vary depending on your insurance plan. Therefore, it is recommended to review your plan's documents or website for detailed information on how to navigate the appeals process effectively.
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In-network pharmacies: Using an in-network pharmacy may be required for coverage
When it comes to getting medication approved by insurance, using an in-network pharmacy is crucial. In-network pharmacies have agreements with insurance providers to offer prescription drugs to members at a lower cost. This means that if you want your prescriptions covered by your insurance, you will likely need to use an in-network pharmacy.
To find out which pharmacies are in-network, you can call your insurance company or visit their website. They will be able to tell you if your regular pharmacy is in-network and, if not, they can provide information on which pharmacies in your area are part of their network. It is worth noting that some insurance plans may require you to use an in-network pharmacy to fill your prescriptions, and using an out-of-network pharmacy could result in limited or no reimbursement.
There may be times when you cannot use an in-network pharmacy. For example, if there is no in-network pharmacy close to you that is open or if you are travelling outside of your insurance's service area. In these cases, your insurance may cover your prescription drugs filled at an out-of-network pharmacy. However, this is not a routine option, and you may need to pay the full cost upfront and then request reimbursement from your insurance company.
To ensure that your medication is approved by your insurance, it is important to understand the specific requirements and limitations of your plan. Refer to your plan documents or contact your insurance provider directly to clarify whether you need to use an in-network pharmacy and what steps to take if an out-of-network pharmacy is necessary.
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Frequently asked questions
Prior authorization is a process where your medical provider must get approval from your health plan before you can have a certain medication, service, or treatment. This is done to ensure patient care appropriateness and treatment cost-effectiveness.
For most medicines, getting approval can take from one to three days after sending the request. If the medicine is urgently needed, insurance companies might decide within a day. For special medicines or cases needing more information, it can take a few days to over a week. If the request is denied and you appeal, it might take weeks.
You can appeal the decision and have it reviewed by an independent third party. You can also ask for a review of the decision. According to a 2023 report, over 80% of initial prior authorization denials are overturned.
You have the right to follow your insurance company's drug exceptions process, which allows you to get a prescribed drug that's not normally covered by your health plan. Your doctor must confirm to your health plan that the drug is appropriate for your medical condition.
