Prior Authorizations

Prescription prior authorization (PA), the insurance rejection that forces me to cringe every time I read it. Prior authorizations are requested by the insurance company and not the pharmacy. However, the pharmacy usually ends up catching the flak as agitated customers stand confused as to why they cannot pick up their prescription that day.

Here's the scenario:

Me: "Your insurance is rejecting the claim for the prescription. They want a prior authorization from the doctor before they are willing to cover the medication."
Customer: "What? But I need my medication."
Me: "I understand and we are willing to fill your medication, but the doctor needs to complete the prior authorization with the insurance before the insurance is willing to cover it if they choose to authorize the coverage."
Customer: "You're holding the prescription in your hand! The doctor must think I need to be on the medication if he wrote the prescription. I need that prescription filled today."

When faced with a prior authorization the pharmacy cannot do anything to force the insurance to cover the medication. The pharmacy will be more than happy to fill the medication, however, if the customer chooses to pick up the medication prior to the authorization the customer must pay for the medication cost in full, or "out of pocket." Too frequently the cost of the medication is insanely high and the customer leaves without the medication. If the customer chooses to pay for the medication out of pocket and the insurance company declines to cover the medication after review, the customer remains stuck with the full cost of the medication which cannot be returned.

The Solution

Though prior authorizations cannot be avoided if the drug is not on the customer's insurance formulary, customers can ease the process by walking in to the pharmacy prepared. First, the customer should understand the basic process of a prior authorization.

1. The prescribing doctor must contact the customer's insurance company via fax or phone and explain why the customer must be on the prescribed medication.
2. The insurance company evaluates the prescription and current medications to determine whether or not the company chooses to cover the medication
3. The insurance company contacts the doctor to inform whether the authorization has been approved or denied.
4. If the authorization has been approved the pharmacy may now resubmit a claim and charge the customer the proper copay according to coverage.

Many insurance companies offer information on what triggers a prior authorization and the forms required by the doctors on their websites. These forms can be printed prior to the doctor's appointment if the customer already knows that the doctor may prescribe a medication not on their formulary. That way the doctor can initiate the authorization before the customer even walks into the pharmacy. Understand, however, that most authorizations take a minimum of 24 hours and more likely in the 48-72 hour range before approval or denial.

Some Major Insurance Prior Authorization Sites

• Caremark
• Medco
• Blue Cross/Blue Shield of CA
• Humana
• Cigna (PDF)
• Tricare