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Prior Authorization for Medications

Prior Authorization for Medications

If you’ve dealt with getting a prescription filled at a pharmacy you may have come across this term at some point. When something requires prior authorization it means the insurance company must approve coverage for it before it can be purchased. Many children with feeding tubes run into this for acid reflux medications but there are other types of medications which also have these sorts of restrictions.

The mechanics for prior authorization can be extremely confusing because policies between insurance companies differ significantly. One company may approve a brand without any objection while it might be nearly impossible to get approval for anything else. If you switched insurance companies you might well find that one brand which was preferred before is almost impossible to get approval for once companies change.

The most confusing part of prior authorization? It’s difficult to predict when you’ll need it. It’s easy to assume you’re in the clear because the first prescription is filled just fine only to find your first refill to need justification. If your second and third month’s refills fill OK that’s still no guarantee things will go smoothly. That fourth month is another trigger point for some companies. Once you do receive prior authorization it needs to be re-justified every single year. You’ve been taking your medication for 15 years? Well, your doctor’s office made a mistake and missed the form. No refill for you!

Manage this by calling the insurance company once a year in or around November. Why call in November? It’s late enough in the year the insurance company will have already decided upon any changes to policy regarding medication prior authorization requirements. Ask the customer service representative if you have any medications which require a prior authorization and, if so, when they are due to be renewed. Make a note of each one where you’ll see it. I notate them in my personal calendar. This lets me know not to wait until I’m out of medicine to refill as I’m typically fond of doing.

If you’re in a bad spot, out of medication, and truly need it right away ask the doctor’s office to:

  1. Fax the prior authorization form and clinical notes together to prevent the need for back and forth between the doctor’s office and insurance company.
  2. Send the fax as a high priority request.
  3. Call in the prior authorization.

I’m a firm believer it’s the little things in life which make the difference between feeling like you’re drifting through chaos or gliding down a gentle river. This is one of the ways I prevent the little emergencies which make life feel chaotic even when it’s not.

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10 responses

  1. I have tardive dyskinesia, vyvanse for binge eating disorder, xenazine for tardive (3k a month), psoriasis (Enbrel dropped from formulary)…let’s see. I could go on. need prior auth for relistor too. Sometimes stuff gets dropped from forulary and they don’t tell you until after the fact. At first of year, you get one mo supply later you get a letter, which they dont’ specifry if it’s a dropped from formulary needing a ‘formulary exception request’ or ‘prior auth.’ last week I was on the phone with my part D, Silverscript, trying to find out what’s what. We tack all prior auths to bullentin board but your idea to call late in the year is great! I met you thru aOpinionated Man.

    Liked by 1 person

  2. Great information for those of us with children needing certain medications or any adult. My son is 19 and considered an adult but he takes Seroquel. Sometimes it is approved, sometimes it’s not. It may also depend on the dosage. This is just from own experience. Thanks for sharing. We could always use great tips on how to interact with these insurance companies.

    Liked by 1 person

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