What is a Prior Authorization?

With so many brand name drugs that don’t have a generic equivalent, you’re likely to hear, “I’m sorry but this medication requires a prior authorization.” Then comes the burning question. What’s a prior authorization? It’s actually simple; that means that your insurance will not cover the drug the doctor has written for you until they complete forms explaining why they have chosen that particular medication. There may be specific criteria that must be met before an insurer will approve your prescription. Those criteria may include things such as symptom severity or even whether you have tried other medications first.

For a prescription that requires a prior authorization, we immediately send your doctor’s office the form to be filled out from your insurer. Many physician’s offices have a person on staff designated to complete these requests. That person will have to access your chart to complete the required paperwork and have the doctor approve it. Once the form is completed and returned to the insurance company, the request will either be approved or denied within a few days. If after several days we don’t have an answer from your insurer, we may suggest that you give your doctor a call to be sure they have communicated with your insurance company.

Prior authorizations are a frustrating but common issue in pharmacy. As insurers try to cut costs, they put more restrictions on the medications they cover. Next time you bring in a new prescription and you hear us tell you it requires a prior authorization, you’ll know what’s going on behind the scenes.  With the physician’s office, pharmacy and YOU all working together, hopefully you’ll have your medication in no time!

Ana Araguz, CPhT
Certified Pharmacy Technician