Getting prior authorization for medication can be inconvenient, stressful, and even delay treatment. BuzzRx explains what it is and shares three ways to get prescriptions if you can’t wait for prior authorization.
Prior Authorization for Medication Can Cause Unpleasant Surprises at the Pharmacy
Imagine that you’re at the pharmacy to pick up prescription medications, right after a doctor’s visit.
Nothing seems out of the ordinary until the pharmacist informs you that your insurance doesn’t cover the new medication and that a prior authorization (also known as pre-authorization or precertification) is required.
Because of this, you’ll have to come back at another time to pick up the new medication. A moment of panic sets in because this medication is supposed to be started immediately.
What is Prior Authorization for Medication?
If this has happened to your older adult or to you, you are not alone.
According to the Kaiser Family Foundation, nearly all Medicare Advantage enrollees are in a plan that requires prior authorization.
In this scenario, you’ll likely ask the pharmacist, “What is prior authorization, and how long does it take?”
Prior authorization is how the health insurance company makes sure a particular medicine is “medically necessary.”
The process of prior authorization serves as a checkpoint to ensure that patients receive appropriate treatment and that no lower-cost alternative is available that would work the same way.
For instance, your insurance company may require prior authorization for a brand-name medication if a lower-cost generic is available.
However, getting a prior authorization can be inconvenient, stressful, and even cause problems if the prescribed medication needs to be started right away.
How to Get Prior Authorization for Medication
If prior authorization is required, note that the doctor’s office, specifically the provider who prescribed the new medication, is responsible for completing the appropriate forms and submitting all supporting documentation.
This may include progress notes, laboratory results, imaging (MRI, X-ray, etc.), and, if applicable, evidence that the patient has “tried and failed” other medications.
After dropping off the new prescription, the pharmacy’s claims system will indicate whether prior authorization is required.
Once this happens, in addition to informing you, the pharmacy staff will notify the doctor’s office of this requirement.
Pre-authorization can take between two and 10 business days, depending on your insurance provider and doctor’s office.
It is a common misconception that prior authorization is the responsibility of local pharmacy staff. The healthcare provider’s office must complete it.
Once the prior authorization request is approved, the usual prescription co-pay still applies.
What if Prior Authorization For Medication Are Denied
If the prior authorization request is denied, you have three options.
- Appeal the decision with the insurance provider (and wait for approval to get the medication)
- Change to a generic medication that insurance will cover (always consult with the doctor)
- Pay 100% of the medication’s cost out of your own pocket
3 Options In Case You Can’t Wait for Prior Authorization Approval
If pre-authorization takes too long, or the insurance provider denies coverage of the medication after appeal, consider these 3 tips to get the needed medication right away at a lower cost.
1. Use a prescription discount card
These free, ready-to-use cards are available to anyone, insured or not, and are accepted at most national pharmacy chains.
These cards can often save up to 80% on prescription medications.
Medication prices can vary significantly by pharmacy, so cardholders should use price tools to look up savings by zip code to maximize savings.
For example, Eliquis is among the most prescribed Medicare Part D medications, yet not all insurance providers cover it.
2. Manufacturer patient saving programs
Brand-name drug makers sometimes offer savings programs so patients whose insurance providers won’t cover a medication can still obtain it at a low or no cost.
Often, these patient-saving programs will be listed on the pharma company’s website, and patients can enroll online.
Approvals for these programs are typically instantaneous. You’ll then receive a code to share at the pharmacy to apply the discount.
3. Nonprofit patient assistance programs
Several nonprofit organizations have missions to help patients access treatments by assisting with out-of-pocket costs.
These programs can be beneficial for those seeking assistance with the cost of new brand-name medications, such as those used to treat cancer.
The PAN Foundation is one popular patient assistance nonprofit that has helped many Americans.
Medicare also has a helpful patient assistance lookup tool where you can search by the name of the drug you need help affording. Sometimes these programs require patients to meet specific income thresholds.
Recommended for you:
- How Seniors Can Get Help Paying for Prescription Drugs
- 5 Options for Drugs Not Covered by Medicare
- 6 Common Medication Problems in Seniors and 6 Ways to Solve Them
Guest contributor: HaVy Ngo-Hamilton, Pharm.D, is a Clinical Consultant at BuzzRx. She has experience in both hospital and ambulatory care settings and is passionate about guiding patients toward better health through medication therapy management and lifestyle counseling. She graduated from Auburn University Harrison School of Pharmacy with a Doctor of Pharmacy (Pharm.D.) degree.
