What is Prior Authorization (PA)?
Prior Authorization is a process required by some prescription insurance plans where extra approval is needed for a certain medication. This means that your provider must provide additional information explaining why this specific medication is necessary for your treatment. Your insurance will review this information and decide whether the medication will be covered under your plan.
Obtaining Prior Authorization
What We Need From You
We will need details from your insurance card, including your Member ID, RxBIN, PCN, and RxGroup. If you have a separate prescription card, please send a picture of both sides of the card to us via chat. You can also contact your insurance using the number on the back of your main insurance card to obtain this information.What To Expect From Us
Prior Authorizations are processed in the order they are received, with urgent requests given priority. The process typically starts when your pharmacy attempts to fill a prescription and is notified that a prior authorization is required. We aim to process requests within 2 business days, but it can take 3-5 business days for your insurance plan to make a decision. You can check on the status of the request by contacting your insurance company.
Expedited Prior Authorization
If your physician believes that waiting for a standard PA decision could seriously jeopardize your health, life, or ability to regain maximum function, an expedited process can be requested. You may also consider paying for the medication out-of-pocket and seeking reimbursement from your insurance if the PA is later approved.
Prior Authorization Approval Process
Once your authorization is approved, inform your pharmacy and check if there is a copay based on your plan. Be aware that any changes in dosage or quantity might require a new authorization.
Insurance Plan Formulary
A formulary is a list of medications covered by your plan, designed to offer cost-effective treatment options. It may not include all available medications but covers a range to treat most conditions. Contact your insurance directly for specific information about your plan’s formulary.
Prior Authorization Denials
If your prior authorization is denied, you can:
Request Alternatives: Contact your insurance for a list of covered medications. Then, consult with your provider to see if an alternative medication is appropriate.
Out-of-Pocket Option: Obtain the medication by paying for it in full. Sometimes, manufacturers or companies like GoodRx have discount cards that be provided to the pharmacy to help cover a portion of the medication.
Submit an Appeal: Follow the instructions in your denial letter to appeal, if applicable.
Plan Exclusions and Restrictions
Plan Exclusion: Some medications are not covered under any circumstances and are listed on your plan’s drug exclusion list. These decisions generally cannot be appealed.
Step Therapy: This requires trying a cost-effective alternative before “stepping up” to a more expensive medication.
Quantity Limit: Your plan may limit the amount of medication covered in a given period (for example, 30 tablets every month).
Clinical Criteria: Medications not deemed medically necessary according to FDA guidelines and your specific diagnosis may be denied coverage.