Sometimes, your insurance may deny a prior authorization (PA). If you’ve received a prior authorization denial, this doesn’t necessarily mean you won’t be able to get your medication. This article provides options and key considerations when navigating next steps.
What to do if your PA is denied
Ask your insurance about alternatives: Contact your insurance and ask for a list of covered medications, then review these options with your provider during an appointment.
Pay out-of-pocket: You can purchase the medication without using insurance and may be able to use discount programs to lower the cost.
Medication cost savings: Research prescription discount programs and coupons for self-pay costs for medications.
Submit an appeal: Follow the instructions in your denial letter to request a review.
Formulary exception: Your provider may be able to submit a formulary exception request if your medication is normally excluded.
Important notes on insurance limitations
Some insurance plans may require you to try a lower-cost alternative before covering the initially prescribed medication.
If a medication isn’t part of your insurance plan, it can’t be appealed.
Some insurance plans will only cover a certain quantity of medication, or base decisions on specific conditions that must be met.
Appeals and exception requests need additional information to make a strong case for why coverage should be approved. Without this justification, these requests will likely be denied.
Your Care Team can guide you through these steps and help communicate with your insurance to make the process easier. Start a chat anytime through the mobile app or web portal.
More about prior authorization appeals and formulary exceptions
You have the right to appeal your insurance’s decision. However, appeals are only successful if:
Circle Medical can submit new documentation that meets prior authorization criteria, or
Circle Medical can provide a strong case for why your care should qualify, even if criteria aren't fully met.
Important note: Your insurance determines the status of your prior authorization. If your prior authorization request is denied and deemed as “not medically necessary,” that final coverage decision is determined by your insurance, not from Circle Medical.
If you’re unsure about what to do, start a chat in the mobile app or web portal, and your Care Team will support you.