What is a prior authorization for medication

Prior authorization—sometimes called precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

The AMA believes that the overall volume of medical services and drugs requiring prior authorization should be greatly reduced.

When it is used, prior authorization should utilize a standardized, automated process to minimize the burden placed upon both physicians and health plans.

As part of its ongoing prior authorization reform initiatives, the AMA offers various reform resources, as well as research and reports, to help minimize the current impact of prior authorization on practices.

Electronic prior authorization videos

Electronic prior authorization videos

Learn how electronic prior authorization (ePA) technology that integrates with practices' current electronic prescribing workflows can improve the drug prior authorization process. Physicians can register to receive 0.25 credits of AMA PRA Category 1 Credit™ for viewing these informational videos. 

Get additional insight and guidance by watching the AMA's 3-part ePA video series:

The Prior Authorization Burden

Simplifying Prior Authorization

A Better Way: ePA and Beyond

Prior authorization tip guide

Prior authorization tip guide

The prior authorization tip guide (PDF) is designed to help practices minimize the burdens caused by prior authorization and increase the efficiency of the process.

There are hundreds of different medications with more becoming available every day. Blue Cross Blue Shield of Michigan and Blue Care Network use prior authorization to make sure you get the right medication.

What is prior authorization?

This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation. 

If you don’t get prior authorization, a medication may cost you more, or we may not cover it.

If you file an urgent request, we will have a decision provided in 72 hours or less. For an urgent review of a non-covered drug, one not on your drug list, we will have a decision in 24 hours or less. A standard request may take up 15 days for us to make a decision.

What kinds of drugs need prior authorization?

• Drugs that have dangerous side effects
• Drugs that are harmful when combined with other drugs
• Drugs that you should use only for certain health conditions
• Drugs that are often misused or abused
• Drugs that a doctor prescribes when less expensive drugs might work better

How do I find out if my medication needs prior authorization?

We cover certain drugs under the pharmacy part of your insurance and others under the medical part of your insurance.

What should I do if my prescription needs prior authorization?

If your drug needs approval, either you or your pharmacist will need to let your doctor know. Your doctor might switch you to another drug that doesn’t need prior approval. They can also submit for a coverage review electronically for commercial or Medicare plans, or by contacting our Pharmacy Help Desk.

What should I do if my prescription drug isn't covered? 

If you review your drug list and determine that your prescription drug isn't covered, please review this page. 

Heading to the pharmacy isn’t usually a fun experience. After you’ve discussed potential treatments with your doctor and selected a medication that you can both agree on, you generally have to wait some amount of time for the prescription to be filled before you can pick it up and return home. And, to lengthen the ordeal further, you may find out at the pharmacy that the medication you were prescribed may need to be pre-authorized to be eligible for prescription drug coverage benefits! That means you could be stuck paying the full cost of the prescription.

At this point, you may be asking yourself what exactly prior authorization for prescription drugs is and how you can get it. HealthMarkets can help provide the answers.

What Does Prior Authorization Mean?

Prior authorization means that your physician must follow a process to obtain prior approval from your insurance company when administering specific medications, medical devices, and medical procedures. Prior authorization must be performed before the insurance company or plan will provide full or partial coverage. Sometimes, insurance companies deny a physician’s request.

Why Do Insurance Companies Require Prior Authorization?

Health insurance companies claim that they need to pre-authorize medications, procedures, and devices in order to keep healthcare expenses low.

What Kinds of Medications Warrant Prior Authorization?

There are several reasons a medication may require a prior authorization request. For example, the prescription may be:

• A brand name medication that is available as a less expensive generic
• Expensive (as with psoriasis and rheumatoid arthritis medications)
• Used for cosmetic reasons (as with hair growth and wrinkle treatments)
• Used at higher doses than normal
• Used to treat non-life threatening conditions
• Deemed medically necessary by your physician (who must also let the insurance company know that other covered medications will be ineffective)

How Can You See If You’ll Need Prior Authorization for Prescription Drugs?

There are several ways to find out if your doctor will need to get prior authorization from your insurance company. First and foremost, you could call your insurance provider directly and ask them. However, if your doctor hasn’t filled out a prior authorization request, you will likely find out at your pharmacy when you try to fill or pick up the prescription.

How Does Prior Authorization Work?

How to Get Prior Authorization (after the fact):

• Call your physician and ensure they have received a call from the pharmacy.
• Ask the physician (or his staff) how long it will take them to fill out the necessary forms.
• Call your insurance company and see if they need you to fill out any forms.
• Check in with your pharmacy (after several days) to see if the prior authorization request was approved. If it wasn’t, you can see why.

Prior authorization works like this:

• Step 1: If your doctor didn’t contact your insurance company when prescribing a medication, your pharmacy will contact them. They will let the physician know the insurance company requires a prior authorization.
• Step 2: The physician (or their staff) will contact the insurance company. They will have to fill out forms and submit a formal authorization request. You can call your physician’s office and ask how long this usually takes.
• Step 3: Your insurance provider may want you to fill out and sign some forms. It would be prudent to call your insurance company and make sure there isn’t anything else they’ll need before reviewing (and hopefully approving) the request.
• Step 4: The insurance company will alert you, your physician, or your pharmacy once they have approved or denied the request. If you’re informed of the decision, contact your physician to let them know the outcome.

How Long Does Prior Authorization Take?

Prior authorization can take days to process, and it depends on what procedure or medication your physician is prescribing and the insurance company providing approval for coverage. According to an American Medical Association study, 40% of physicians employ staff whose only job is to work on prior authorizations, and they spend approximately 13 hours per week completing them.1

Within a week, you can call your pharmacy to see if the prior authorization request was approved. If it wasn’t, you can call your insurance company to see why the authorization was delayed or denied.