pharmacy « Struggling to Thrive

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.

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This is never fun for anyone but it can be especially difficult for medically complex children. Instead of a doctor’s office or two, there’s a medical supply company, the pediatrician, and all of their specialists. Prior authorizations have to be submitted to the correct insurance, so you may need to update insurance information with doctors you haven’t even seen yet!

Tip #1 – Call the new insurance company. They won’t be able to tell you much until the insurance activates, however, you can request a case manager be assigned before the transition. This gives you an advocate on the inside that already knows your situation before the paperwork starts flowing.

Tip #2 – Call and update insurance info with all of the doctors who write a perscription for your child. That way if there are any issues at the pharmacy which require additional paperwork from the doctor’s office the responses get sent to the correct location.

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