Why Does My Prescription Need a Prior Authorization?
You had your appointment, talked through your options with your provider, chose a medication, and the prescription was sent to the pharmacy. Then you hear, “Your medication needs a prior authorization.” Suddenly, something that seemed pretty straightforward has turned into phone calls between the pharmacy, your clinic, and your insurance company.
If you have never dealt with a pharmacy prior authorization before, it can be incredibly confusing. The simplest explanation is this: a prior authorization is an extra approval your insurance plan may require before it agrees to cover certain medications. Your provider has already decided that the medication is appropriate and written the prescription. What is being reviewed is whether your insurance will pay for it under your specific pharmacy benefits.
The frustrating part is that several different people and organizations may be involved, and each has a different job. So, let’s untangle the thread.
What is a pharmacy prior authorization?
A prior authorization, sometimes called a PA, is a coverage requirement used by insurance plans for certain prescription medications. Before agreeing to cover the medication, the plan may ask your healthcare provider for additional information showing that you meet its coverage criteria.
Those requirements can vary dramatically between insurance plans. One plan may cover a medication without any additional paperwork, while another may require documentation of your diagnosis, medications you have already tried, side effects you experienced, or a reason a lower-cost or preferred medication would not be appropriate.
This is why two people taking the exact same medication can have completely different experiences at the pharmacy. The medication did not change. Their insurance coverage did.
Who is involved in a prescription prior authorization?
There is the prescriber, who determined that the medication is clinically appropriate, and the clinic staff, who often gather records, complete insurance questions, submit documentation, and follow the request through the process.
There is also the pharmacy, which receives the prescription and submits a claim through your pharmacy benefits. If the insurance plan requires prior authorization, the pharmacy usually receives that message when it tries to process the prescription and then notifies the clinic.
Finally, there is your insurance plan or pharmacy benefit manager, often called a PBM, which applies the coverage rules and ultimately decides whether the request meets the plan's requirements.
That is also why the name on your prescription insurance card may be different from the name of your medical insurance company. Companies such as Caremark, Express Scripts, and Optum Rx commonly administer pharmacy benefits for other health plans.
What happens after the pharmacy says a prior authorization is needed?
When your pharmacy runs the prescription through insurance and receives a prior authorization requirement, it usually sends that information to the prescriber. From there, the clinic may need to answer questions about your diagnosis, treatment history, previous medications, doses, side effects, laboratory results, or why the requested medication is medically appropriate.
Sometimes this is quick and straightforward. Other times, insurance requires considerably more information.
For certain medications, your plan may also require step therapy, meaning you must first try one or more medications the insurance company prefers before it will consider covering another option. If you have already tried those medications, they did not work, caused significant side effects, or are not appropriate for you, your provider may be able to document that as part of the request.
It is important to remember that an insurance company's preferred medication is not necessarily the medication your provider believes is the best choice for you. Those are two different decisions.
Why do insurance companies require prior authorizations?
Prior authorizations are one type of utilization management. Insurance plans use them to apply coverage criteria, encourage the use of lower-cost alternatives when appropriate, review certain higher-cost medications, and make sure specific requirements are met before paying for a prescription.
There can be reasonable goals behind that process, but there is also no question that prior authorizations create additional work and can delay treatment. What looks like a simple prescription from the patient's side may involve multiple electronic requests, chart reviews, forms, insurance questions, and follow-up before the medication can actually be processed.
Both things can be true: there may be a reason for the review, and the process can still be frustrating.
Why do I need a prior authorization if I have taken this medication before?
This catches patients off guard all the time. Prior authorization requirements are based on your current insurance plan and its current rules, not simply on whether you have successfully taken the medication before.
You may suddenly need a new authorization because your insurance changed, your employer selected a new pharmacy benefit, the insurance formulary changed, your previous authorization expired, your dose or quantity changed, or the plan updated its coverage requirements.
Sometimes absolutely nothing changed about your treatment. Something changed administratively.
“The pharmacy said they’re waiting on my provider.” What does that mean?
This phrase causes a lot of confusion because it can mean several different things. The pharmacy may truly be waiting for the clinic to submit the request, but the clinic may also have already submitted it and be waiting for insurance to respond. Insurance may have requested more information, an approval may have come through but the pharmacy still needs to rerun the claim, or there may be another insurance issue that initially looks like a prior authorization problem.
There are several moving pieces, and unfortunately, repeatedly calling one part of the chain does not always make another part move faster.
If your pharmacy tells you a prior authorization is required, it is completely reasonable to contact your clinic once to make sure the request was received. After that, some of the process may simply be happening somewhere you cannot see.
What happens if the prior authorization is denied?
A denial does not necessarily mean your provider changed their mind or that someone decided you should not take the medication. It means the insurance plan did not approve coverage under the request as it was submitted.
The plan may require another medication to be tried first, additional documentation may be needed, the medication may be excluded from your benefits, or the request may not have met a specific coverage rule.
Depending on the reason, your provider may be able to submit additional information, request an exception, appeal the decision, or discuss another medication with you.
Your provider's clinical recommendation and your insurance company's coverage decision are related, but they are not the same decision.
Does prior authorization approval mean the medication will be cheap?
Unfortunately, no. Prior authorization determines whether the insurance plan will allow the medication to be covered. It does not determine your final out-of-pocket cost.
Even after approval, your prescription may still be subject to your deductible, copay, coinsurance, formulary tier, quantity limits, or specialty pharmacy requirements.
So, yes, it is entirely possible to spend days getting a medication approved only to discover that it is still expensive.
Because apparently healthcare needed more than one kind of confusing.
What can patients do to make the process easier?
One of the most helpful things you can do is keep a reasonably accurate medication history, especially if you have tried several medications over the years. Knowing what you took, approximately how long you took it, whether it worked, what dose you reached, and why it was stopped can be extremely helpful when insurance asks about previous treatment.
You should also make sure your clinic has your current medical and pharmacy insurance information. If your insurance changes, letting your healthcare providers know before you need a refill can sometimes help identify coverage problems sooner.
Most importantly, remember that a delay does not always mean someone forgot about your prescription. There may be quite a bit happening behind the scenes.
The bigger picture
Prior authorizations are one of those parts of healthcare that most people never learn about until they are standing at a pharmacy counter wondering why a medication their provider already prescribed is not ready.
The provider chooses the medication, the pharmacy submits the claim, insurance checks its coverage rules, the clinic provides medical information when required, insurance reviews the request, and the pharmacy processes the prescription again once a decision is made.
All for one prescription.
Understanding the process does not make waiting for medication less frustrating, but hopefully it makes the space between “your prescription was sent” and “your prescription is ready” a little less mysterious.
At Mending Mental Health, medication management does not always end when a prescription is sent. Our team regularly works behind the scenes with pharmacies and insurance plans to help patients navigate coverage requirements when they arise.
We wish that part of healthcare were simpler. Until it is, we will keep helping our patients untangle it.
Pharmacy Prior Authorization FAQs
How long does a pharmacy prior authorization take?
The timeline varies by insurance plan, medication, and whether additional information is requested. Your clinic may submit the prior authorization quickly but still have to wait for the insurance company to review it.
Does prior authorization mean my medication was denied?
No. A prior authorization requirement usually means insurance needs additional information before making a coverage decision.
Who approves a medication prior authorization?
The insurance plan or the organization administering your pharmacy benefits makes the coverage determination after reviewing information supplied by your healthcare provider.
Can the pharmacy complete my prior authorization?
The pharmacy usually identifies the prior authorization requirement and notifies the prescriber, but the clinical information needed for the request generally comes from your healthcare provider.
