How Prior Authorization Affects Your Prescription Drugs  

Blues Perspectives

| 3 min read

Man reviews his prescription drug bottle
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 may be another step in the process for certain drugs: prior authorization. This is a program designed to confirm you’re getting the right medication, at the right time, for the right price. Prior authorization is helping Blue Cross Blue Shield of Michigan and Blue Care Network protect our members from receiving the incorrect medication or dosage. Here’s what you need to know about the prior authorization process: 

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. It’s an important safety check, and it helps ensure you receive the most appropriate and most cost-effective medication for your health condition. If a medication requires prior authorization and the request is not approved, you may pay more out of pocket or your plan may not cover it at all. 

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 online account or Blue Cross mobile application 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. For mobile application, select My Coverage and then Prescription to find pricing and coverage of your medication. Doctors and pharmacists typically have an understanding of what requires prior authorization, so be sure to ask questions and stay informed throughout the process.

How long does it take to get a medication authorized?

When an urgent review of a drug not covered by your plan is requested, Blue Cross will make a decision in 72 hours or less. Standard drug reviews may take up to 15 days to decide, but when all information is provided decisions are often made within a few days. Some drugs can be reviewed through an electronic prior authorization (ePA) process and sometimes decisions can be made within minutes.

What types of drugs require prior authorization?

Drugs that have dangerous side effects, that are harmful when combined with other drugs, that you should use only for certain health conditions or that are often misused or 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, a list of drugs requiring prior authorization is available online. Share this information with your prescriber so he or she understands if prior authorization is required for the medication being prescribed.

If my drug needs prior authorization, what happens next?

Your doctor may switch you to a different drug at his or her discretion or contact your insurance carrier to start the approval process. Blue Cross also offers physicians the ability to use its electronic prior authorization process for drug reviews to expedite the process and lessen the administrative work for the physician. Interested in learning more about your pharmacy coverage? You may also enjoy these posts:
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MI Blues Perspectives is sponsored by Blue Cross Blue Shield of Michigan, a nonprofit, independent licensee of the Blue Cross Blue Shield Association