What is a PRIOR AUTHORIZATION?

I had a technician a few years ago that just didn't seem to understand why all our patients didn't immediately know all pharmacy lingo. Every week a patient would get an insurance denial on their prescription with a response from the insurance, "PRIOR AUTHORIZATION REQUIRED."

And every time my tech would say to the patient, "Sowwy, we need a Prior Auth."

And most of the time, the patient would reply, "What do you mean, Prior Auth? My doctor already authorized it!"

From there the conversation would just get worse until I would step in and explain everything. I finally became tired of the same scenario playing out over and over. So I had to explain to my technician that most people have NO IDEA what she was talking about and we need to take the time to explain what it means to every patient.

So what is this "prior authorization" crap and what does it mean to me, Peter Patient?

MOST PEOPLE have prescription drug insurance. Cigna, Medco, Aetna, WellDyne, Big Jim's Health Co-op, CVS/Caremark... or a state-funded Medicaid (which really isn't insurance) or Medicare part D. Every insurance has a number of underwriters and every plan has a different "formulary." A "formulary" is a list of medications that are covered under the plan. NOT EVERY DRUG prescribed is on your formulary. Expensive medications are usually NOT on most formularies. It is so complex that prescribers have no way of knowing what your specific insurance will cover and won't cover. Sometimes they go the extra mile and will contact the insurance before you leave the office to see if a specific med is covered, but MOST of the time you'll get all the way to the pharmacy before you find out.

At the pharmacy we type up your prescription and send it off electronically to your insurance for payment. Basically we're billing your insurance electronically and it will immediately tell us what your co-pay will be -- the amount we charge you in the pharmacy. Sometimes we'll get a message back that the medication isn't covered at all. For example, most insurance will not cover Vitamin D and you'll have to pay "out of pocket" if you want it. 

THEN there are the few times that the insurance sends back the dreaded message, "PRIOR AUTHORIZATION REQUIRED." What this means is that your insurance has a few questions for your doctor... they want to "authorize" payment "prior" to us dispensing it. They want to know if the doc has tried other therapy with you or if there is another medication on the formulary that they will cover that will be just as effective. 

One example... your cholesterol is high and your prescriber wants to put you on Crestor (which doesn't have a generic currently). Some insurance will ask for a prior authorization and they'll want to know if you've tried "lifestyle changes" first or what your HDL and LDL lab values indicate... perhaps you can get adequate cholesterol reduction from taking the generic Zocor at a fraction of the cost of Crestor, thereby saving money for all the insured members of your plan.

So once we get a request for a P.A. (Prior Authorization) we'll contact the doc to let them know. Usually we fax over a form. Sometimes the doc will get back to us right away, other times it takes a few days. Rest assured WE MAKE MONEY from processing prescriptions so we're going to do everything we can to get the correct information where it needs to be. So don't let a "prior authorization" scare you... most of the time it just means a slight delay in getting your medication.