Patient Information Regarding Prior Authorization
“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 Carine Family Medicine or the 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 10-45 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:
Why we are prescribing that specific medication
Which other medications your have tried before and the outcome
Whether or not you have tried and failed medications on their preferred drug list (sometimes they will make you retry a medication that was ineffective for you or caused side effects if we can not document that you tried it within the last 90-180 days – that is correct, their policy is that even if you tried a medication last year that did not work or that caused side effects, they can require that you try it again before they may authorize the medication we prescribed for you)
Finally, after this information has been reviewed by your insurance company, they decide on whether or not they will cover the cost of your medication, and they notify your pharmacy, our office, and you.
Another frustrating aspect of this process, is that even if we know your insurance company and know which medications may require a PA, there is no way for us to begin this process proactively. We can only respond to the PA request after we have received it. The exact procedure is not necessarily uniform across all of the specific coverage plans offered by an individual insurance company. Also, we typically are required to reference the information by using a specific identification number that is generated by the company for each prior authorization.
Obviously, this is a time and labor-intensive process. We have to hire staff members who spend most of their time simply working on prior authorizations. Several medical practices have started to refuse to do this due to the time and money required, and simply tell their patients that they will not do PA’s and will only prescribe medications from a limited formulary of what the insurance company refers to as it’s “preferred drug list” (a list of predominantly older/generic medications for which a prior authorization is not required).