What is a prior authorization?

A prior authorization is a formal approval a health insurance may require prior to your pharmacist dispensing a specific medication. When you submit a prescription your pharmacist may tell you that a prior authorization is needed. The pharmacist will then contact our office to inform your doctor.

What does prior authorization entail?

On our end the process can be slow and very time consuming. We have to get the proper forms from your insurance on line and your doctor needs to provide detailed documentation about your health condition including when you were diagnosed with the condition the medication is for and what other treatments you have tried (including dates, dosages, how long you took a medication and what the effect was). 

Why is there a related charge ?

There is a charge for this service because it can be very labor intense.

We can not guarantee that the insurance will agree to cover the medication even after we go through the process. Our office will contact you and make you aware of the fee prior to initiating a prior authorization for the first time. It may be less expensive for you to buy the medication outright than to pay us for the labor of going through the prior authorization process.

Why might a prior authorization be declined?

The fact that your insurance refuses to cover the medication automatically has nothing to do with providing you with good care. Sometimes, authorization is declined because a medication is available over-the-counter, or because the particular formulation is not what was selected for the insurance company’s formulary. Sometimes only a certain amount of a medication will be approved for use in a year.

What happens if it is declined?

There is no guarantee that your insurance will cover the medication. If your insurance does not cover the medication you can:

• pay for the medication outright at the pharmacy

• ask your doctor to prescribe an alternative medication (if one exists)

• file an appeal with your insurance company. In our experience the appeal often ends up with another denial.