Prior Authorizations

Medication prior authorizations (also known as pre-authorization, prior approval, or pre-certification) are requirements set by health insurance providers that require healthcare professionals to obtain approval or authorization before prescribing certain medications. It is a process to ensure that the prescribed medication meets the insurance company's criteria for coverage and is medically necessary.

Here's how the medication prior authorization process generally works:

1. Prescription submission: When a healthcare provider determines that a specific medication is appropriate for a patient's condition, they write a prescription for that medication.

2. Prior authorization request: Before the prescription is filled at the pharmacy, the healthcare provider or their staff must initiate the prior authorization process. This involves submitting a prior authorization request to the patient's insurance company.

3. Review by insurance company: The insurance company evaluates the prior authorization request based on specific criteria. This may include reviewing the patient's medical records, considering alternative medications or treatments, and assessing whether the requested medication meets their coverage guidelines.

4. Decision and notification: The insurance company will communicate their decision regarding the prior authorization request to the healthcare provider or their staff. This decision can be an approval, denial, or request for additional information.

   • Approval: If the prior authorization is approved, the healthcare provider can proceed with prescribing the medication, and the patient can obtain it from the pharmacy with coverage from their insurance.

   • Denial: If the prior authorization is denied, the insurance company typically provides a reason for the denial. The healthcare provider can then explore alternative medications or treatments or initiate an appeal process to challenge the denial.

   • Request for additional information: Sometimes, the insurance company may require additional information from the healthcare provider to make a decision. In such cases, the healthcare provider must provide the requested information promptly.

5. Appeal process: If the prior authorization is denied, the healthcare provider or patient can appeal the decision by providing additional documentation or making a case for the medical necessity of the prescribed medication. The appeal process varies depending on the insurance provider and may involve submitting written documentation or engaging in direct communication with the insurer.

The goal of medication prior authorizations is to ensure appropriate use of medications, control costs, and promote evidence-based prescribing practices. However, the process can introduce administrative burdens and potential delays in accessing necessary medications. It is important for healthcare providers and patients to be aware of the specific prior authorization requirements of their insurance plans and work together to navigate the process effectively.

When you are filling a prescription, the pharmacy has no way of predicting which medications will require a prior authorization. This can potentially cause delays in your medication. By signing up for our Med Sync program can help alleviate some worry around your refills and ensures proper communication between your prescribing physician and the pharmacy.