A prior authorization (PA) is common terminology in pharmacies, but I find it to be very confusing for our patients. Has this ever happened to you? You visit your doctor, discuss prescription options together, review the chosen medication and side effects, and then you get a call from the pharmacy. “This medication needs a prior authorization,” the pharmacy staff member tells you. “Isn’t the prescription the authorization?” most people ask. It would seem so.
Let’s take a step back: the prescription is basically your healthcare provider communicating to the pharmacy what medication should be filled. Believe me, pharmacists love nothing more than filling prescriptions problem-free without having to follow up on rejected prescriptions all day long. We would rather fill what the doctor sent us, provided that there are no drug interactions, allergies, or other serious issues, than make you wait.
Who Needs a Prior Authorization?
Unfortunately, there is a middle man, the insurance company, that has a say. Insurances, together with your employer, or whomever provides your prescription benefits, develop a formulary. The formulary, which can be found on your plan’s website or app, or by calling member services for a copy, defines what medications are covered at what rate. Prior authorizations often arise with injectable medications, chemotherapy, newer medications, or brand-name medications that have a generic available, to name a few.
Another common PA issue arises from “step therapy.” Say your doctor prescribes the newest, most expensive, brand-name nasal steroid. The insurance may want to ensure that you have tried less expensive, generic alternatives that are proven to work just as well. If you have not tried a generic, your insurance most likely will not pay for the expensive medication unless your doctor proves that you tried and “failed” the less expensive medication(s).
As a pharmacist, sometimes I am surprised to see a rejection come back for a drug that is not even expensive. Although we fill prescriptions for cyanocobalamin (vitamin B12) vials for injection all the time, one insurance recently required a PA for route of administration, even though the cost of the medication was only a few dollars. Every insurance has a different procedure for which drugs need PA.
Some people have plan designs with straight copays, where they pay, for example, $10 for a generic medication, $25 for a preferred brand name medication, and $50 for a non-preferred (more expensive) brand name medication. Other plan designs have deductibles to meet, for example, you may have to pay the first $3,000 of your health care costs including medical and prescription costs, before copays kick in. Either way, a PA may need to be addressed.
What Do You Do About a Prior Authorization?
Ok, so your medication needs a PA – now what? In most cases, the pharmacy team forwards the information to the prescribing doctor, who usually does one of two things:
1- The doctor can provide the insurance with clinical documentation as to why you need this particular medication over a less expensive alternative.
2- The doctor can switch your medication to one that is covered on your formulary and that does not require a PA.
Occasionally, with some insurances, the pharmacy is able to initiate the PA process. In this case, we contact the insurance, and they reach out to the doctor. No matter what, to get the initial drug approved, the doctor will have to provide supporting clinical information to your insurance. This process may take anywhere from minutes to days, usually at least 24 hours.
Why Might You Need a Prior Authorization?
For an even more thorough understanding of the PA process, I consulted Suzanne Florczyk, PharmD, who is a pharmacist specializing in prior authorizations. She explains that it is a common misunderstanding that insurances just don’t want to pay for certain medications. Rather, she says, “There is a hierarchy of what needs to be followed. The government dictates what is covered based upon FDA-approved drugs.” She further explains, “When a doctor prescribes a drug, it needs to be looked at if it is necessary to see if your diagnosis follows how it should be prescribed (no off-label uses) and is the most cost-effective for the patient.” (Side note- this page explains off-label uses: https://www.fda.gov/forpatients/other/offlabel/default.htm)
I understand that it must feel frustrating when your medication needs a PA and is not immediately available, especially after discussing options with your doctor and feeling comfortable with the plan for treatment.
What Insurance Companies Are Trying to Accomplish:
Looking at it from the insurance’s point of view, they are trying to keep unnecessary costs down. An example is a brand-name drug called Duexis, which contains two drugs – ibuprofen (Motrin) and famotidine (Pepcid). Both medications are available over the counter (OTC), but together as a brand name product, the price is astronomical: over $3,000 for a one-month supply! If you need a PA for this drug, it will likely be denied. However, you can ask the pharmacist to help you find those two drugs OTC, and assist you in figuring out how to create the equivalent dose that your doctor prescribed. There are also prescription versions of both ibuprofen and famotidine that will likely be covered by your insurance- the doctor can easily write two new prescriptions. If the insurance were to shell out this excessive amount of money for medications like Duexis when there are several ways to get the same medication at the same dose for a fraction of the price, healthcare costs would be sky high. PA is one way of keeping costs in check, and passing those savings on to the patients.
Another medication I have seen numerous PA requests for is the lidocaine 5% patch for pain. Often the PA is denied, and the cash price is about $175 for 30 patches. However, we have had many patients purchase OTC lidocaine 4% patches at a fraction of the price and obtain quite a bit of relief. When it’s allergy season and your medication is not covered, there are drugs of every kind available OTC. Same with heartburn medications.
Prior authorizations may feel frustrating but if you work with your team of doctors and pharmacists, you should be able to receive the medication that you need, or a very similar medication that will be just as effective.