Prior Authorization

Insurance companies don’t approve all care automatically. Sometimes a plan requires prior approval or pre-authorization. This means that before you can get coverage for certain medications, tests, procedures, surgeries and medical devices, your insurance company will request additional information from your doctor before making a payment decision.

Each insurance company is different, but usually you or your doctor will be asked to do one or more of the following:

• Call a special phone number at the insurance company.
• Fill out a special form.
• Provide extra information about you.

Sometimes this includes paperwork showing what other medications you’re taking or recently took, and other medical information. Your insurance company’s website will usually list the medications and services that require prior authorization. The web address and phone number are typically printed on the back of your insurance card.

Prescriptions that usually need prior authorization include:

• Medications that are prescribed when less expensive options may work
• Medications with serious side effects
• Medications that could hurt you if taken with other medications
• Medications that should be used only for certain conditions
• Medications that could be misused or abused
• Medications with age restrictions
• Medication prescriptions that instruct you to take a different amount than what is allowed by your insurance
• Medication prescriptions that instruct you to take the medication for a different length of time than what is allowed by your insurance

Here are some other things to remember:

• Your pharmacy will usually call your doctor to get the process started for prescriptions that require prior authorization. For Medicaid, your pharmacy or doctor needs to call your state provider services to start the process.
• Ask your doctor if you need to take additional steps for the prior authorization. Sometimes an insurance company wants you to send in other paperwork.
• Allow the doctor’s office and insurance company (and the state in the case of Medicaid) enough time to complete the prior authorization (usually one to three days).
• Check back with the health care professional to see if the prior authorization was approved.

If your medication is not approved, you can call your insurance company or your state Medicaid program to find out why. The phone number is on the back of your insurance card. If your prior authorization isn’t approved, your medication or service may cost more or may not be paid for at all. When this happens, some doctors will decide to change your prescription to another medication that your insurance will cover or recommend a different service. Remember, you can always appeal these decisions, too. Read more about the appeal process