Patient Information Regarding Prior Authorization For Prescription Medication
“WHAT IS A PRIOR AUTHORIZATION?”
Frequently, patients ask questions regarding prior authorization (PA) of their prescriptions. This can be a confusing process to understand and is frequently a source of great frustration for both patients and our office as well. We have prepared the following information to help you better understand this process.
Often times, patients are told by the pharmacy or by their insurance company that the delay or the reason that their medication was not covered was the responsibility of their clinician. Patients are frequently told that ‘’your doctor just needs to call or send a letter”. This is quite simply untrue.
Prior authorization is essentially the process through which your insurance company decides whether or not they will cover the cost of medication that has been prescribed to you. The important thing to understand is that this is a decision made by your insurance company – not by Indiana Health Group or your clinician. If you are interested in the specifics of the prior authorization process, you can read about the details below.
“HOW DO PRIOR AUTHORIZATIONS WORK?”
In the past, prior authorization was only required for the newest , most expensive medications. However, currently, far more prescriptions require prior authorizations. Basically, the process works like this:
You attempt to have a prescription filled at the pharmacy.
The pharmacy enters the information into their system and if your medication requires a PA, the pharmacy is notified at that point and a request for a PA is generated by the system.
The PA request is sent from the insurance company to our office. Sometimes, you may receive a copy of this letter as well from your insurance company. Although you may receive a copy of this letter, it is the responsibility of the insurance company to contact us regarding the PA, so you do not have to do this yourself. In addition to the copy of the PA request, patients are sometimes sent letters encouraging them to ask their doctor about switching to a different, less expensive medication. Sometimes these are reasonable recommendations such as suggesting a change to a generic equivalent (generic version of the same medication), but often times they are actually asking the patient to change to a generic alternative (sometimes a completely different category of medication). The language used in describing these recommended changes is often confusing and unclear.
After we receive the request for the PA, our office will respond to the insurance company as quickly as we can. Part of the difficulty in handing these requests is that there is not a uniform way to do this for all companies, or even all insurance plans offered by the same company. For example, some companies require that we provide information to them via an online form. Others require that we fax them records, while some will fax us a specific form to complete and send back to them. Finally, a number of companies require that one of our medical assistants call them on the phone to answer questions regarding the PA. It is not unusual for our medical assistants to spend 5-20 minutes on hold or being transferred form one person to the next trying to provide the required information, plus the time in providing the information once the appropriate party is reached. The required information is different for each situation, typically the insurance company wants to know: