Have you ever gone to pick up a prescription and heard, “Your medicine needs a prior authorization”?
This can be confusing and frustrating, especially when you need your medicine. Here is a simple look at what a prior authorization is and why it happens.
What Is a Prior Authorization?
A prior authorization, also called a PA, is when your insurance company wants more information before it will pay for a medicine.
This does not always mean your medicine was denied. It usually means your insurance company needs your doctor’s office to show why you need that medicine.
Why Does My Medicine Need One?
Insurance companies may require a prior authorization for different reasons. For example:
The medicine is expensive.
Your insurance prefers a different medicine.
Your plan wants you to try another medicine first.
The dose or amount needs to be reviewed.
The medicine is being used for a certain health condition.
Your insurance plan has special rules for the medicine.
Each insurance plan has its own rules.
What Happens Next?
When the pharmacy gets a message that a prior authorization is needed, the pharmacy may send information to your doctor’s office.
Your doctor’s office then works with your insurance company. They may need to send medical records or explain why the medicine is needed.
The insurance company reviews the information and makes a decision.
They may:
Approve it: Your insurance will cover the medicine based on your plan. Keep in mind that “covered” does not always mean free. You may still have a copay, coinsurance, or deductible amount to pay.
Deny it: Your insurance will not cover the medicine at this time. A denial is not always final.
Ask for more information: Your doctor’s office may need to send more details.
What If My Medicine Is Denied?
A denial does not always mean “no” forever. You and your doctor often have options:
Your doctor’s office can appeal the decision by sending more information or explaining why you need the medicine.
Your doctor may be able to request a review directly with a doctor at the insurance company.
Your doctor may suggest a different medicine that your plan will cover.
Ask your doctor’s office what the next step is if your medicine is denied.
How Long Does It Take?
Prior authorizations are not always completed right away. Some may take a few days, while others may take longer.
Your pharmacy may help start the process, but the pharmacy does not make the final decision. Your insurance company decides whether the medicine is approved.
What Can You Do?
If your medicine needs a prior authorization:
Make sure your pharmacy has your current insurance information.
Watch for calls or messages from your doctor’s office.
Respond quickly if your doctor needs information from you.
Ask your pharmacy if there are any updates.
Ask your doctor if another covered medicine may be an option.
If you are running out of an important medicine, tell your pharmacist or healthcare provider.
Your Pharmacy Is Here to Help
Prior authorizations can feel like an extra roadblock between you and your medicine. Your pharmacy can help explain what is happening and work with your healthcare team to keep the process moving.
Remember: A prior authorization does not always mean “no.” Sometimes it simply means your insurance company needs more information before it says “yes.”
