Why do I need a prior authorization?

"When I went to fill my prescription, I couldn’t get it right away. Why did my pharmacist tell me I needed a prior authorization?"

Thumbnail of Why do I need a prior authorization?

With the rapidly changing pharmaceutical landscape there are new drugs brought to market every year. Some drugs are new to market with never-before-seen therapies, while others, known as me-too drugs, are different drugs that do the same thing as an already established medication. With so many options on the market, IPM uses a prior authorization program to ensure patients are receiving a medication that will effectively treat their condition but won’t break the bank.

What types of medications typically need prior authorization?

  • Medications prescribed with dosages higher than approved by the FDA
  • Medications with known significant side effects
  • Expensive medications, such as biologics used to treat rheumatoid arthritis
  • Specialty medications used to treat unique conditions
  • Medications that are intended for specific conditions but prescribed for different conditions

My prescription is one that needs prior authorization. Now what?

If your prescription falls under one of these categories, you will likely be introduced to the concept of step therapy. Step therapy is the name given to the process where patients are prescribed the most cost-effective medication first, (oftentimes, a generic).  If that medication fails to produce the desired results the patient will progress to more costly therapies.

For you as the patient, you can wait while the behind-the-scenes work is done for you.  Your doctor will need to formally submit a prior authorization request form that indicates the medical necessity of your prescribed drug. The provider and insurance will work together until the prior authorization is either approved, redirected, or denied.

Often, your pharmacy will provide information on alternative formulary medications to your prescriber before you go to the pharmacy and a therapeutic change in medication may be the result.

What happens if my medication goes through the prior authorization process and it is still denied?

You have a couple options at this point. One option is you can file an appeal through your prescriber. The prescriber can appeal a denial with additional information or literature support indicating your care would be harmed by not receiving the medication or that alternative medications have already been tried and didn’t work. Your appeal is reviewed by a physician Medical Director or a Pharmacist to determine medical necessity or in some cases, may be sent to an independent third party to ensure an impartial review.

The second option is to choose to pay for the medication out of pocket. IPM offers a pharmacy discount program, BuzzRx®, that will automatically process claims that are rejected by insurance and process them through this additional money-saving program. If a medication is not covered, and there is a BuzzRx discount available, the discount takes effect automatically at the point of sale.

How can I be more involved?

The old adage, knowledge is power, is especially true when it comes to your health. As you increase your health literacy you will be more empowered in each step of your health care journey. The next time your doctor starts to prescribe a new medication, ask them why they are making that specific recommendation. Is there a generic version of this medication available? Will this medication require prior authorization?  Are there other options that will be available to me immediately? By discussing your prescription options, you empower yourself to be a partner in your healthcare decisions.