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Prior Authorization

Some drugs and medical services need to be approved or have Prior Authorization from the insurance company before you get the service or prescription. Following the process for prior authorizations will save you lots of time and energy trying to get something paid for after the fact.

Not all drugs and medical services are approved right away by your insurance. Sometimes you need something called a Prior Authorization. When your pharmacist fills your prescription, he or she will find out if your drug needs a prior authorization. This means before you can get your prescription filled or have the service, the insurance company must get more information from your doctor before it will make a payment decision. Usually he calls your doctor, who will start the process and call your insurance company. Each insurance company may ask your doctor to follow different steps. Usually the steps are one or more of the following:

  • Call a special phone number at the insurance company.
  • Fill out and fax a special form your insurance company created.
  • Fax extra information about you. Sometimes this includes paperwork showing what other drugs you are taking or recently took, and other medical information. 

Your insurance company will usually list the medications and services that require a prior authorization on their website. The web address is typically printed on the back of your insurance card or you can call the number on the back of your insurance card.

Drugs that usually need a prior authorization include:

  • Drugs that are prescribed when less expensive drugs may work
  • Drugs with serious side effects
  • Drugs that could hurt you if taken with other drugs
  • Drugs that should be used only for certain conditions
  • Drugs that could be misused or abused
  • Drugs with age restrictions
  • Drug prescriptions that instruct you to take a different amount than what is allowed by your insurance
  • Drug prescriptions that instruct you to take the drug for a different length of time than what is allowed by your insurance

Here are some other things to remember:

  • Your pharmacy will usually call your doctor to get the process started for prescription that requires prior authorization. For Medicaid, Your pharmacy or doctor needs to call your state provider services to start the process.
    Ask your pharmacist or doctor how long it will take for them to do this process.
  • Ask your doctor if there are additional steps that you need to take for the prior authorization. Sometimes an insurance company wants you to fill out other forms or send in other paperwork.
  • Allow the doctor’s office and insurance company (and the state in the case of Medicaid) enough time to complete the prior authorization (usually one to three days).
  • Check back with the healthcare professional to see if the prior authorization was approved.
  • If your medicine is not approved, you can call your insurance company or your state Medicaid program yourself to find out why. The phone number is on the back of your insurance card.

If your prior authorization isn’t approved, your drug or service may cost more or may not be paid for at all. When this happens, some doctors will decide to change your prescription to another drug that your insurance will cover or recommend a different service. However, sometimes you may want to appeal, depending on why your prior authorization was denied.

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