Why Do Prescriptions Need Prior Authorization? Here’s Why!

Posted March 23, 2020 by Michael Chamberlain - See Editorial Guidelines

Have you ever walked into a pharmacy to fill a prescription and been told that it needs prior authorization?

What can be more confusing is that the prescription is already written and approved by the doctor, and the pharmacy still refuses to fill it until prior authorization.

The below article will clear these doubts by giving a clear understanding of what a prior authorization is, how to get it, what can you do when you don’t get it, and much more

First, let’s get a clear answer summary of what a prior authorization is, then we’ll go through more of the process to help you understand what’s going on here.

What Is Prior Authorization? Prior authorization is a process whereby insurance companies need to approve certain prescriptions before a pharmacist can fill it. Required only for insured patients, the reasons for prior authorization vary from cost-effective treatment, appropriate use, and assessing other interactions.

But before we head into further detail, let’s understand what a prior authorization really is.

What Is Prior Authorization

Prior Authorization

Prior authorization is approval, required by the insurance company, to fill certain medications.

It’s not an approval needed by your doctor as many of us mistake it for. It’s more like a “challenge system” put in place by your insurance company, which will allow the insurance company to decide whether or not to cover specific drugs.

So, without a prior authorization, your insurance provider may be able to deny you coverage for a certain medication or treatment. This leaves you with the bill to handle on your own.

This doesn’t affect cash-paying customers at all, as it’s only related to patients who have insurance coverage. Meaning, patients who bill their prescriptions through insurance will only be affected by this prior authorization. So, patients who are uninsured or pay in cash will have nothing to do with prior authorization, nor will they be affected by this process.

Why Prescriptions Need Prior Authorization

There are plenty of reasons why certain prescriptions need prior authorizations to be filled. However, frustrating it may seem, the reasons are mainly very practical ones. Some of the most common reasons for prior authorization are as follows:

  • The prescribed medications may be unsafe when combined with other medications the patient is taking 
  • The medication prescribed has low-cost alternatives which are equally as effective
  • When the medication prescribed is used only for a very specified set of health conditions 
  • When the medication prescribed can be easily abused or misused 
  • When the specified drugs are used for cosmetic purposes 
  • When the prescribed brand-name drugs have a generic available 
  • When the prescribed medications are intended only for a certain age group 
  • When the prescribed medicine and its doses show adverse health effects or even dangerous interactions 
  • If other cheaper or alternative medications have been tried and failed at first 
  • When the drug is not covered by your insurance but is deemed medically necessary by the doctor 

In most cases, prior authorization is needed to ensure the medication is appropriate for the patient and that the most cost-effective treatment is being used. 

Why You Need Prior Authorization And The Benefits

Prior authorization helps patients to lower the cost by giving them a chance to try other cheaper alternatives available, which may be equally effective.

The prior authorization process also allows the insurance company to review the prescriptions and make sure they do not have any interaction with other medications the patient is known to be taking at the same time, which the doctor may be unaware of. 

It also helps insurance companies to make sure one is not prescribed with medications that may not be necessary.

This also offers a chance to prevent addictions that can be caused by the prescribed medication and to understand if the patient is at the right age and of suitable health condition to be using them. 

Nevertheless, it’s also an opportunity for insurance providers to manage the cost of other expensive medications that may be medically necessary.

Likewise, prior authorization provides many benefits for patients, such as avoiding dangerous interactions while making sure cost-effective medications are obtained. 

Is Prior Authorization Only For Prescriptions?

Prior AuthorizationPrior authorization applies mostly to prescriptions, but depending on the insurance plan, it may also apply to certain healthcare treatments, services, or supplies.

If one is using a healthcare provider in the insurance plan, then the prior authorization process will be handled by the healthcare provider. It’s the healthcare provider who will ultimately be responsible for obtaining prior authorization.

In the cases where one doesn’t have a healthcare provider included in the insurance plan, the customer/patient will have to handle this process directly with the insurance company.

If one fails to obtain prior authorization, the service or supply will have to be obtained by paying directly as a straight transactional process.

How To Know If A Prescription Needs Prior Authorization

If a prescription needs prior authorization, the pharmacy will notify the healthcare provider who will give the necessary information to the insurance company. The insurance company will then decide whether or not to cover the specific medications. 

This process of deciding by analyzing the conditions will, on average, take up to two days.

The pharmacy will inform you of the condition of the approval. If prior authorization has been approved, you will need to fill the prescription immediately. This is because prior authorization is set for only a specific period. If you fail to fill the prescription within this time period after approval, then you will have to re-apply again for future fills. 

What To Do If A Prior Authorization Is Denied

From 2-10 days after submission, the pharmacist will inform you if the prior authorization has been approved or denied. Sadly, an insurance company can deny prior authorization, meaning you will need to pay the full price for the medication as a retail transaction. 

However, if you believe the authorization has been denied incorrectly, then you can submit an appeal.

Prior Authorization Appeal Outcome

Appeals can work out favorably to get prior authorization, especially when the doctor states the prescription is medically necessary for the patient.

For this, you can obtain the necessary documentation from your doctor to show the prescription is medically necessary. Or, if there are any clerical errors, then an appeal may also turn out to be successful.

However, it’s quite normal for prior authorization to be a time-consuming process. To avoid, or minimize this, if you feel a medication needs prior authorization, it’s recommended that you check with the insurance company directly – in advance.

Also, some pharmacies may allow you to purchase the medication on a credit card until the prior authorization has been approved, and then reimburse you later if it hasn’t been denied.

To Close

We hope this has been useful in understanding how the prior authorization process works, and why it’s in place.

However frustrating it may seem, we need to recognize that the insurance companies must take a lot of factors (and responsibility) into account when authorizing a medication and they do so to keep costs down for everyone, and with your interests in mind.

Prescription Hope works with over 180 pharmaceutical manufacturers and utilizes their patient assistance programs to provide you with a flat-rate cost for your medication. Enroll with us to find out if you are eligible to pay only $50 a month for each of your medications.