Prior Authorization: How It Impacts Your Pharmacy Coverage

Prior Authorization: How It Impacts Your Pharmacy Coverage

When you receive a new prescription, you might assume that all you need to do is head to the nearest pharmacy and pick it up. However, there’s often another step in the process: prior authorization. This is a program designed to confirm you’re getting the right medication, at the right time, for the right price. It is important to understand prior authorization, so we put together a primer so you know what to do if a prescription requires it.

  1. What is prior authorization and why is it necessary? Prior authorization is the process of your insurance carrier reviewing a new prescription and your medication needs before your plan approves coverage. Blue Cross Blue Shield of Michigan and Blue Care Network have the program in place to ensure the most effective drug that provides the highest value to you is prescribed. If a medication requires prior authorization and you don’t get it, you may pay more out of pocket or your plan may not cover it at all.
  2. How do I know if my medication requires prior authorization? If you have pharmacy coverage through Blue Cross or BCN, you can log into your account to see if your prescription requires prior authorization. You will need the name of the medication, the dosage and frequency. For more specific instructions on navigating the member portal for prior authorization needs, follow the instructions in the “How do I find out if my medication needs prior authorization?” section here. Doctors and pharmacists typically have an understanding of what requires prior authorization, so be sure to ask questions and stay informed throughout the process.
  3. How long does it take to get a medication authorized? When doctors file a standard request, it typically only takes a few days (but can take up to two weeks depending on the circumstances). In cases that are life threatening, when your doctor files an urgent request, it will take less than 24 hours to gain approval.
  4. What types of drugs require prior authorization? Drugs that have dangerous side effects, that are harmful when combined with other drugs or that are often abused usually require prior authorization. Prior authorization is also needed when a less expensive drug may work better. Although this doesn’t apply to every prescription, there are many on the list.
  5. If my drug needs prior authorization, what do I do next? Once you’ve confirmed that your prescription requires prior authorization, you or your pharmacist will need to let your doctor know. At that point, your doctor may switch you to a different drug at his or her discretion or contact your insurance carrier to start the approval process.

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Photo credit: Bruce Guenter

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