What is Prior Authorization?
Prior authorization is an approval required by many health insurers before they will cover certain prescriptions, procedures or tests. It’s a process frequently related to step therapy or ‘fail first’ policies, which typically require patients to try a less expensive or generic medication first before covering the original, specific medication a doctor prescribes.
It Matters
Obtaining a prior authorization can be a time-consuming process for doctors and patients that may lead to unnecessary delays in treatment while they wait for the insurer to determine if it will cover the medication. Further delays occur if coverage is denied and must be appealed. Disputing or appealing a prior authorization request requires a physician to file an appeal – often by mail or fax – which may take several days or weeks to process. Some plans, including plans offered as part of Medicare Part D, are required to respond to a physician within 24 hours for expedited cases. However, the American Medical Association (AMA) reported in a 2006 study that processing prior authorization requests used around 20 hours per week of physician, nurse and clerical staff time. Additionally, a survey by the AMA found that 69 percent of physicians wait several days just to get a response on a prior authorization request for medication.
Because there are few standard procedures or forms for submitting prior authorization requests, confusion and frustration with the process are common among healthcare professionals. A 2012 survey conducted by the Medical Society of the District of Columbia found that 93 percent of surveyed physicians believed that prior authorization protocols had a “very negative” or “somewhat negative” impact on their ability to treat patients.
What can you do?
In many states, there isn’t a uniform process or paperwork to address prior authorization requests, leading to considerable expense in both time and money for doctors, and a potential delay in treatment for patients.
In an effort to achieve a more streamlined and efficient process, several states have introduced or passed legislation to create a uniform application process for prior authorization. For example, in 2010, in response to a request to simplify the prior authorization process, the Minnesota Department of Health produced a unified form for both prescription prior authorization and step therapy exception requests.
Most notable about Minnesota’s law is a stipulation that prior authorization requests must be able to be submitted and accessed electronically by January 1, 2015. Electronic submission in conjunction with a standardized prior authorization process could increase efficiency by eliminating downtime between phone calls, faxes and standard mail.
The value of standardized prior authorization process has been increasingly recognized, with laws being enacted in Michigan and Maryland in 2013. The Maryland Health Progress Act of 2013 includes a provision that requires certain insurers to accept the prior authorization of another insurer. In Massachusetts, work is underway to standardize prior authorization by replacing 150 prior authorization forms with one form.
If you find yourself waiting a long time to get your medication, talk to someone in your doctor’s office to find out the status of the prior authorization and if you can do anything to help. It is important to alert your doctor’s office if there is a delay in the prior authorization to avoid any potential lapse in treatment, as this could affect your health.
Resource Center
- Video: Barriers to Patient Access: Prior Authorization
- Position Statement: Prior Authorization
- Infographic: Prior Authorization Delays Access to Vital Medications
- Infographic: How Prior Authorization Impacts Access to Care
Find out if there is proposed legislation in your state and take action.
Heading to the pharmacy isn’t usually a fun experience. After you’ve discussed potential treatments with your doctor and selected a medication that you can both agree on, you generally have to wait some amount of time for the prescription to be filled before you can pick it up and return home. And, to lengthen the ordeal further, you may find out at the pharmacy that the medication you were prescribed may need to be pre-authorized to be eligible for prescription drug coverage benefits! That means you could be stuck paying the full cost of the prescription.
At this point, you may be asking yourself what exactly prior authorization for prescription drugs is and how you can get it. HealthMarkets can help provide the answers.
What Does Prior Authorization Mean?
Prior authorization means that your physician must follow a process to obtain prior approval from your insurance company when administering specific medications, medical devices, and medical procedures. Prior authorization must be performed before the insurance company or plan will provide full or partial coverage. Sometimes, insurance companies deny a physician’s request.
Why Do Insurance Companies Require Prior Authorization?
Health insurance companies claim that they need to pre-authorize medications, procedures, and devices in order to keep healthcare expenses low.
What Kinds of Medications Warrant Prior Authorization?
There are several reasons a medication may require a prior authorization request. For example, the prescription may be:
- A brand name medication that is available as a less expensive generic
- Expensive (as with psoriasis and rheumatoid arthritis medications)
- Used for cosmetic reasons (as with hair growth and wrinkle treatments)
- Used at higher doses than normal
- Used to treat non-life threatening conditions
- Deemed medically necessary by your physician (who must also let the insurance company know that other covered medications will be ineffective)
How Can You See If You’ll Need Prior Authorization for Prescription Drugs?
There are several ways to find out if your doctor will need to get prior authorization from your insurance company. First and foremost, you could call your insurance provider directly and ask them. However, if your doctor hasn’t filled out a prior authorization request, you will likely find out at your pharmacy when you try to fill or pick up the prescription.
How Does Prior Authorization Work?
How to Get Prior Authorization (after the fact):
- Call your physician and ensure they have received a call from the pharmacy.
- Ask the physician (or his staff) how long it will take them to fill out the necessary forms.
- Call your insurance company and see if they need you to fill out any forms.
- Check in with your pharmacy (after several days) to see if the prior authorization request was approved. If it wasn’t, you can see why.
Prior authorization works like this:
- Step 1: If your doctor didn’t contact your insurance company when prescribing a medication, your pharmacy will contact them. They will let the physician know the insurance company requires a prior authorization.
- Step 2: The physician (or their staff) will contact the insurance company. They will have to fill out forms and submit a formal authorization request. You can call your physician’s office and ask how long this usually takes.
- Step 3: Your insurance provider may want you to fill out and sign some forms. It would be prudent to call your insurance company and make sure there isn’t anything else they’ll need before reviewing (and hopefully approving) the request.
- Step 4: The insurance company will alert you, your physician, or your pharmacy once they have approved or denied the request. If you’re informed of the decision, contact your physician to let them know the outcome.
How Long Does Prior Authorization Take?
Prior authorization can take days to process, and it depends on what procedure or medication your physician is prescribing and the insurance company providing approval for coverage. According to an American Medical Association study, 40% of physicians employ staff whose only job is to work on prior authorizations, and they spend approximately 13 hours per week completing them.1
Within a week, you can call your pharmacy to see if the prior authorization request was approved. If it wasn’t, you can call your insurance company to see why the authorization was delayed or denied.
Find Health Coverage With HealthMarkets
Whether it’s deductibles or prior authorizations, HealthMarkets can help you understand the ins and outs of your current coverage, as well as help you review your health insurance options. Call to speak with a licensed insurance agent today, or apply for a plan online.