Prior Authorizations

When a patient takes a prescription to the pharmacy, and the pharmacist tells the patient that the prescription requires prior authorization, it means that the insurance company does not cover the medication prescribed.

At this point, the doctor has several options:

1. Change to a covered medication

   The physician can simply prescribe a medication covered by the insurance plan.

2. Request prior authorization from the insurance company

   The physician can request that the insurance company pay for the medication prescribed.

   The insurance company will only cover the requested medication if certain established criteria are met.

   In order to determine whether the criteria are met, the physician may need to talk with the patient again. If so, I require the patient to return for a separate office visit.

3. Do nothing

   If the patient does not meet the insurance company's prior authorization criteria for the medication being prescribed, but there is no viable alternative medication, the physician will simply tell the patient that the insurance company does not cover the medication prescribed.

   At this point, the patient can pay for the medication out-of-pocket if the patient so chooses.

When the doctor submits a prior authorization request, the insurance company either approves it or denies it.

• If the insurance company denies the prior authorization request, the patient can ask the doctor whether there are any alternative approaches to the condition being treated. Sometimes there are; sometimes there aren't.
• If the insurance company approves the prior authorization request, the patient can then go to the pharmacy and fill the prescription.