Prior Authorization How do you get insurance companies to approve medications



hi Josh here with pharmacists tips.com to talk a little bit today about prior authorization and how you get insurance companies to approve medications this is a frustrating process for pharmacists for patients for doctors but it is something in the modern world that we have to deal with so the more we understand the easier it can be first off why won't the insurance cover your medication and what is this thing the pharmacy is telling you requires prior authorization it means that it needs a pre-approval by your prescription insurance because either cost or safety of the medication there may be a therapeutic alternative meaning a medicine that will achieve the same effect or treat the condition that may be safer or cheaper or the medication may be not may not be on the formulary of your prescription insurance the formulary is just a long list of medications preferred by your insurance company and it varies from company to company so it's worth calling your insurance company see if you can get a copy of it oftentimes you can log on to their website and print out a copy of the formulary you can take that with you to the doctor and that can save a lot of time and headaches in the future because you your provider can find you a medication that they know your insurance will cover another reason is it may require step therapy meaning you have to try a generic first let's say you're a type 2 diabetic and your provider wants to put you on a newer diabetes medication well your insurance may deny it if you haven't at least tried metformin first metformin is a generic diabetic medication it's been around a long time and it has been shown to work really well so that would be an example of a step therapy they're not going to cover it till they it's been proven that you've failed some of the tried-and-true cheaper methods for treating the condition and some medications may simply just not be covered by your insurance many weight loss medications are not covered by insurance cosmetic things things like for wrinkles for a hair removal for improving eyelash growth those are not going to be covered we're seeing more and more over-the-counter items within the same class so a lot of like heartburn and reflux acid suppressing medications now that they've become available over-the-counter without a prescription many plans have just stopped covering the prescription versions some cough medicines are not covered by certain insurance companies erectile dysfunction drugs oftentimes not covered by insurance companies and I'm gonna have a detailed or I do have a detailed summary at pharmacist tips calm /pa just it goes into a little more detail and explains this so how does the prior authorization process work the pharmacy usually starts or you know the doctor maybe even will know right away this medicine will probably require prior authorization as a pharmacist I always try to come up with an alternative if there is a possibility that will work the same that I know their insurance will cover or you know we just go ahead and before the insurance contact information to the doctor's office then the doctor or prescriber will determine whether they can change the medicine to something else that will help treat the condition or they will contact the insurance company the health care provider then will begin completing the forms they may be a form they fill out in fax in or a web form or an email or sometimes they can do them over the phone also the pharmacy and doctor may use a service like the website cover my meds just expedites the process makes it easier to determine how to contact the insurance company because it varies by each insurance so how long does it take to get it approved it again it varies by the insurance company and the medication you know how how much documentation the insurance company wants what the whole process is medications that are needed immediately often can you can request an expedited process but typically is the between one and four business days what what if you want the brand name medication what if your doctor does not want you to use the generic will the insurance pay for that first off typically the doctor has to write the prescription is brand name only letting the pharmacy know that they don't want the generic used or using the code da w1 this varies by state and of course country as to how this works but typically the doctor is going to have to specify on the prescription only a brand name medication to be used most insurance companies then will reject the claim saying that they'll require a prior authorization before the brand name is covered and then typically if approved it's gonna be a fairly high copay if from my experience once it is approved it's gonna cost of course a lot more than that generic so what do you do with the insurance deny is denies the medication says no way to the prior auth what you can pay cash course you can talk to your doctor about finding a generic alternative or you go through that step therapy process that your insurance company may have in place you can take your formulary in to your doctor and see if they can find a medicine on that or you can file an appeal with the insurance company and you know it can be a headache but if if it's what you need for your condition it's something you just may have to do I appreciate you watching my video I do hope that this provided you some understanding of the prior authorization process again it you know it really it can be a headache for doctors pharmacies patients but unfortunately it's necessary to keep costs under control for insurance companies prescriptions can get very expensive and if they covered every prescription the cost of insurance would go up so it is sort of a necessary thing albeit frustrating and subscribe to my channel if you appreciate the information that I provide in these videos I'd really appreciate it thanks

9 comments

  1. dude!!! THANK YOU! Dear god im so confused about this whole prosses.my insurance hasn't covered a medication for over 2 years yet I know of other people at my work with the same insurance that get it covered.. im actually thinking about getting a lawyer.

  2. Why do gastro doctors offices claim 4-6 weeks in order to get a pre-auth for Hep C DAA drugs? What could possibly take this long?

  3. thanks, it really did help.
    I know what it's like to get a prior authorization, you're correct when you said it's a headache. Yikes!😔

  4. I have an experience of 7 years in a California based long-term care pharmacy , IAM from India, can I get part time job please let me know, I have much knowledge in submitting prioauthorization forms

  5. I’m going to search your videos to see if you have one about prior authorization for maintenance medication, but I’ll still ask my question here if that’s alright.

    I suffer from a chronic cough condition and I have been taking a narcotic type syrup since 2010. Prior to January, this year, my pulmonary Dr was able to write a 3 month supply on the required handwritten script so I wouldn’t have to drive across town every 30 days. My new insurance will not allow this courtesy and will only authorize 60 days worth to be doled out every 30 days with a fresh handwritten script. I also must get a new authorization when the 60 day approval expires.
    The insurance rep told me there’s no appeal process for me to attempt to get a broader authorization time frame, does this sound legitimate?

    Also…

    Doesn’t my Dr have any input regarding this being an ongoing maintenance medication?

    Thank you for any insight!

  6. Having switched insurance companies at the beginning of December '17, I have been having difficulty getting my script for Dronabinol 2.5 mg filled. My GI, and pharmacy have been working on this persistent problem. I am not an Aids pt, nor a cancer pt.
    But, but, I am living with a host of chronic pain, and digestive issues. I lost my stomach due to gastroparesis, and have narrowing of my esophagus, as well as a surgical sticture , due to a Nissan Wrap that had been placed over 14 years ago. I have a J PEG for most of my nutritional needs. I also suffer from almost constant N/V. I do have Phenergan, and Ondansetron 4mg ODT to have when not home. The Dronabinol helps not only with the nausea issue, but helps spark a bit of appetite in me. Since losing my stomach, I no longer feel hunger, like I used too. I don't understand why almost 2 months later, and I am still nowhere with BCBS. If I could pay full price for this every month, it wouldn't be an issue. I've been on this med for over 3 years, and BCBS has covered this in the past…. how many appeals do I have to file. I feel for my poor Doc's office, and my poor pharmacy as well…. it's not like they have any other patients to tend to…. So frustrating for all parties involved. I am lucky to have a great team of doctors and pharmacists (plus the pharmacy techs) taking care of me, trying to advocate the best they can. I also regularly contact my insurance. How do you deal with this type of issue × god only knows how many pts at any one time needing prior auth, and maintain your sense of sanity????
    Please forgive me, for being long-winded, still can't fall asleep 0039 in the morning due to nausea and vomiting.

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