The People's Perspective on Medicine

Breaking Down a Prior Authorization

Waiting for a prior authorization for your prescription can be frustrating. Here's an explanation of what they are and how they work.

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.

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I get several PA requests daily. I do not have time allotted in my schedule to do these. I have to do them on my personal time. Please be patient and understanding. If you can bring your formulary with you or call your insurance company and find out an alternative drug that would be helpful.

I have had these problems so many times. I have tried step-up therapy many times to no avail, but somehow the company does not seem to retain all this info. At one point I sent a 10 page letter to the insurer with every bit of info I could find on the history of this ailment and RX, and they finally granted it, with my doctor’s request as well. Now for many drugs there are 15 different generics, and it is possible one of those would work as well as the brand name, but there is no way to try different ones and experiment. Most drug plans only carry one brand, and if that doesn’t work, you are stuck with mountains of paperwork.

My husband has had this happen mid year at least 3x over the years- same doctor, same diabetes dx, same insurance. It’s insulin folks! Not something off label; so not-new that insurance paid for it 3 mo. earlier without batting an eye. I think the insurance systems have gremlins working for them.

I have been prescribed an $800 a month med with no hassle. Yet, a $10 generic that I have taken for decades now requires a prescription. This makes no sense.

I’ve run into this problem several times. Sometimes it’s extremely frustrating (and expensive, while you pay cash if you can’t take anything else), and other times it gets taken care of quickly. I try to be patient with the doctor’s office as I know they are usually swamped with paperwork like this, and none of it reimbursable to the office. It’s the insurance companies I find most unhelpful. Things get lost, don’t get noted on the computer, on and on. I usually try to help the doctor’s office by making frequent calls to the insurance company to help things along. It gets frustrating, though, and I get tired of having to spend so much of MY time on it. We need single payer insurance, for sure.

My mother has to do this once per year, as she takes a very expensive brand-name-only narcotic. She has tried multiple generic narcotics, all with fairly catastrophic results. The insurance company has, fortunately, always approved this exception to their formulary, but it does have to be renewed annually. So, that is something your readers might wish to keep in mind when in need of a prior authorization – the need to check how long the PA is good for.

Surprising I am male 80, a professionally qualified analytical accountant and survivor under National Health Rules, but for how much longer? The health v profit, is the same in both Countries but is failing as the pressure of funding health tourism, destroys UK culture. Same applies in different forms to Social Security and Pensions, State and Private. The USA is also Profit-led.

The UK is, I am advised, is about the size of Texas, a mere pinhead on the mighty rump of the Rhino. (Pig is more popular, but challenges friendship). Just imagine if there had been no Boston Tea Party? or 1689 Bill of Rights, all originating in England. Great Britain, is an understatement. Therefore I do not condemn, but attempt to expose common abuse.

Everything is profit-driven. Funded by a Government that believes it can scrape the dust from voters and non voters pockets, just to ensure it has no value and thereafter limit the service provision.

I would have considered that the American Bill of Rights would protect against medical profiteering that affects the sick. In reality nobody demands that x or y make drugs and therefore are entitled to make profit. Profit is necessary, but extreme profit is the bed of corruption. All lobby groups should be outlawed as have been ‘Pay Day Loan’, in the UK.

Attending a UK hospital recently, I ask the senior nurse what was the difference between an NHS Registrar and Consultant, her instant reply was ‘the number of security trucks necessary to carry away their pay.’

The collapse of the American Mortgage System, was down to the ‘Henry Ford Perfectly within the law Dream’, dictate, In order to develop new technology, we must charge existing buyers more, very quickly grabbed by the Mortgage industry, because it facilitated unregulated lending reads[Profit] and disaster for all fringe borrowers.

But the NHS, is not the answer as everytime the NHS Budgets for future years it grossly overstates the financial requirement and upon receipt must spend it, usually on added management. Politicians love it, because they can offer the impossible dream.

So the World is constrained by totally ridiculous enemy of the people namely ‘Professionalism’ whereby the majority upon receipt of their pass grade, rush to the nearest sink and drain their brain, as it has no future value as their place in society, is guaranteed. By far the worse are the self regulating professions such as Law and Politics. Wealth without Social Contribution.

Remember if you can survive 80 years of corruption, in some perverse way, you have won.

For those of you who ABSOLUTELY must have something that you can’t substitute for, read no further. I resent the Prilosec my doctor prescribes to then being told I can buy it over the counter, which is always cheaper. Happens to me all the time.

Since this became an issue with my (voltaren) generic gel about three years ago, the physician charges $30.00 to do the paperwork for a P.A. every year.

Please keep in mind that an office may get 10-40 P.A. requests per day. The request is handled by the RN, LPN or CMA after clinic hours are finished at my office. Many requests require a list of previous medications tried, the date started and the date stopped and why; this requires a bit of record review to be accurate. Most requests require at least 10 minutes to complete and others even longer. Office software is supposed to “green flag” a medication as a preferred to head off these problems, but isn’t always correct. Some insurance companies change their preferred list twice a year.
It really doesn’t matter what the doctor and patient discussed or what was decided at the office visit. The insurance company has final say. Some medications will not be approved despite the P.A. filed or info submitted. It’s always about the money!

When my prescription plan changed, suddenly EVERY prescription has needed a PA…even for medications which I have taken for years. The prescription plan says that it is for my “protection”.

As a result, I have sometimes had to wait for weeks before medication for an acute problem could be dispensed. I have paid for medications myself when my condition was desperate. Insurance companies have refused drugs and demanded I take other drugs-even after the doctor provided facts that showed the bio-equivalent the insurance company wanted me to use HAD BEEN unsuccessful and the newer medication was the natural progression. Doctors tell me repeatedly “You must try XXX medication, although I doubt it will be as effective until we can have data to give the insurance that it doesn’t work well considering your other health problems”.

I PAY Insurance premiums every month much higher than the costs of any of the medications and office visits. I am seriously wondering what value add the prescription plan is for me. I was forced into a retiree Medicare Advantage plan. It seems, as a consumer procuring insurance as a service, that I am not really a customer…because my opinions, my experiences, my unhappiness, and my health do not matter to the insurance companies at all.

In the end, I believe managed care procured almost solely through employers has ruined healthcare in America…operating costs for doctors and pharmacies are astronomical – and despite all the HIPPA agreements I sign…the people in charge of Insurance companies all see and know more about my health history , and make assumptions for care, that take my personal information and give it to data scientists and lowly paid clerical employees who can easily steal my entire identity.

Unfortunately, doctors, nurses and pharmacists are the only people who listen and agree. In the meantime, politicians are getting millions in pharma PACs.

Thank you for this article. We are dealing with this issue now.

Why don’t all pharmacy’s take some of the steps to help you that are mentioned?

The third option for the doctor is to ignore the request until the patient calls several times. This is the pattern I encounter often.

As a former pharmaceutical company employee, I think it is ridiculous that insurance companies and pharmaceutical lobbyists have the right to determine what my doctor thinks is best for me. Big Brother is doing more than watching. He is controlling the quality and length of our lives.

This is quite interesting and informative to me. I’ve dealt with PA issues 2-3 times due to a couple of medical issues that I’ve had (still do). I was put on a $3,000 injection med (I gave it to myself ona nightly basis for 24 months). It required a PA which was granted with no fight.

The article mentions the Lidocaine 5% patch. I was prescribed it as an off label use – for back pain – and a PA was granted for it for 12 months. A renewal was denied as they were only allowing them for shingles patients by that time.

Well guess what?! Soon after that I was indeed – for real – diagnosed with shingles! A NP in a totally different practice with no connection to the practice where they were using the patches on me is who diagnosed it – it was caught quickly before I had a total outbreak- I actually only had a single shingle but went in to see this NP colleague of my PCP because I didn’t know what it was.

Ok – she sent me back to the other practice with the shingles diagnosis and they confirmed it. The PA paperwork got lost – unknown to anyone. I called the insurance company inquiring about the status and was told they didn’t have a record of a PA for me on the Lidocaine patches.

The lady I was speaking with did a conference call to my doctor’s office and got one of the nurses on the phone – she told them that she was trying to do a conference call – and then and there she filled out the PA request with information from the nurse and me.

The PA was granted in just a few hours due to the insurance company having lost the original PA request! I just filled the last box allowed on the PA. Somehow, and I don’t know how, I have a stockpile of 3-4 boxes of patches in addition to the one I’m using from!

All it took was that single shingle! I didn’t have any more of them to break out – the NP did put me on a 7 day med they use for shingles and got no fight from the insurance company.

“whomever provides your prescription benefits”
Please. There must be beaucoodles unemployed English majors available for proofreading at reasonable prices.

We recently learned that if the doc’s office calls the pre-auth folks a second time (yes, it must be called in separately) and tells them there is no other medication that will work (the first time they say the med is necessary–but usually don’t get asked if it is the only one that can be used) THEN our script insurance (Tricare through Express Scripts) cut the co-pay in half from $50 to $25 — only if they are told no other medication can be used.

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