Hassle-free Pharmacy Authorizations

Prior authorization is a process that involves obtaining an approval for a prescribed device, procedure, service, or medication from health plans before it is administered as designed. Pharmacy prior authorization is the requirement for approval from the patient’s health plan for a prescription drug. Insurers allow usage of appropriate medications only after thorough consideration of the patient’s health outcome and value to the plan sponsor. Services that require pre-authorization are approved based on clinical needs and will not be qualified for payment until the conditions for approval are met.

Common requirements include the patient’s diagnosis, treatment history, the specific medication being prescribed, dosage, and duration of therapy. Supporting clinical documentation may also be needed.

When a request is denied, both you and your patient can appeal the decision. Our team can guide you through the appeals process and help you overturn the denial.

Health insurance companies use a PA as a means to essentially put a restriction in place to reduce unnecessary prescription drug use and cost of the service. Prescribed medications are approved after verifying the medical necessity to ensure it is the most economical option viable for the health condition. If a less expensive but equally clinical effective alternate is available after review, then the cost-friendly option is recommended by payers. It is an evidence-based process that minimizes overall medical costs to improve affordable healthcare access for patients. For example, if the physician prescribes an expensive drug, the insurance company may authorize it only if the physician can show that it is a better option than a less expensive medication for the condition.

Each insurance company has a team of physicians, pharmacists and other medical specialists who review and research to create the list of newly approved medicines and existing medicines. They also consult medical practitioners to develop guidelines and administrative policies for pre-authorization. Insurance companies most likely subject the following kinds of drugs to PA:

• Brand name medicines that are available in a generic form
• Expensive medicines, such as those needed for psoriasis or rheumatoid arthritis
• Drugs used for cosmetic reasons such as medications used to treat facial wrinkling
• Drugs prescribed to treat a non-life-threatening medical condition
• Drugs not usually covered by the insurance company, but said to be medically necessary by the prescriber
• Drugs usually covered by the insurance company but are being used at doses higher than normal

Blue Cross Blue Shield requires prior authorization for those drugs that:

• have dangerous side effects
• are harmful when combined with other drugs
• should be used only for certain health conditions
• are often misused or abused
• are prescribed when less expensive drugs might work better

Obtaining prior authorization for medication is a time-consuming process for physicians and their staff. According to AMA’s prior authorization survey 2023, physicians and their staffs spend 12 hours per week completing PAs. Typically, the pre-authorization process can range from a few days to weeks for a successful result, but may take longer in some cases. The time it takes for prior authorization to be successfully completed depends on numerous factors such as type of medicine, the payer’s rules, and the communication speed between the healthcare provider and insurance company. The main factor influencing the decision for PA approval is the quality of the healthcare provider’s documentation. Errors or discrepancies in the clinical notes, lack of information about previously tested medication or ambiguity about the state of patient’s disease could potentially lead to delay in the PA process. In the same AMA report, 27% physicians report that PAs are often denied. Further delays occur if coverage is denied and must be appealed. An appeal can take several days to process.