An Ultimate Guide to prior Authorization for a prescription

Imagine going to the pharmacy to fill out your prescription, only to find out the prescription needs prior authorization. You will be wondering why do I need to have prior authorization when I have a doctor’s prescription.

The authorization is not from your doctor, it is from your insurance company.

What is a prior authorization?

Prior authorization is requested by insurance companies for certain medications. This is to reduce costs and in turn support you with comprehensive healthcare plans for your benefit.

Prior authorization is required for medications that fall in the following categories

  1. When an alternative generic medicine for an expensive rand name medicine is available.
  2. Medication is being utilised for cosmetic reasons.
  3. Medication that is neither preventative nor used for non-life-threatening conditions.
  4. Medication is only used by certain age groups or disease conditions.
  5. Medication prescribed by your healthcare provider which they felt was necessary but was not covered by insurance.
  6. There is a potential for serious side effects if the user takes those medications.

In such circumstances, prior authorization is required to verify the necessity of the medication by the insurance company.

 How do I get prior authorization?

In most cases, the healthcare provider arranges for prior authorizations. The doctor will submit a prior authorization form to the insurance company and get the approval

Sometimes, the pharmacies also support you in getting prior authorizations by coordinating with the doctor and providing the information requested to the insurance provider.

Please note, the prior authorization is for a specific amount of time and you will need another authorisation if you need the medication in the future.

 How long do prior authorizations take?

The amount of time a prior authorization might take differs and a set timeline cannot be shared. However, the doctor or the pharmacy need to submit for prior authorizations as quickly as possible so there are no delays in your medication.

 What if my prior authorization request is denied?

You or your doctor can submit an appeal if prior authorization is denied. It will be best to attached documentation such as test results etc which highlight why a certain medication is necessary to ensure that prior authorization is approved.

If there is certain urgency for the medication, you can pay from your pocket or credit card and you will be reimbursed later if the prior authorization is approved.

However, if the authorization is still denied, you will, unfortunately, have to pay for the medication out of pocket.

 Deliver My Meds

Deliver My Meds is an online prescription delivery service based out of Long Island, New York. Dedicated to serve the community and help them with all their healthcare-associated needs in a professional, competent and efficient manner.