What Is Pre-Authorization? (also called “Prior Authorization” or “PA”)
An insurance company may require a patient to get its approval before it agrees to cover the cost of a prescribed drug. This is known as pre-authorization or prior authorization (PA). PA can make sure a medication is right for you and provides the most cost-effective treatment option. However, pre-authorizations that are not appropriate or timely may also cause serious and dangerous delays to patients.
When a clinician writes a prescription for a medication, they may not know if the insurance company will require PA. It is often your pharmacy or other individuals involved in your treatment who learn whether the prescription needs to be authorized by the insurance company before it can be filled. When PA is necessary, your clinician’s office will need to file the necessary forms explaining why you need that particular medication. This means extra work for the medical office and often a delay before the patient can get their prescription.
Some patients may want to give up because the PA process can take so much time. For cancer patients, a delay in getting needed medication can be risky because these medications are necessary to control their cancer. So, don’t give up!
When prior authorization is granted, it is usually for a specific length of time or a course of treatment. Patients and their clinicians must ask for this authorization again if a refill is needed.
If the insurance company does not approve use of the drug, the patient has several choices. They can ask their doctor to prescribe a different drug than the one that was first prescribed, they can pay out-of-pocket for the full cost of the medication, or they can appeal the insurance company’s decision with the help of their cancer team. Very often, appeals will result in approval of the medication. It’s usually worth appealing, unless there’s another drug that your doctor thinks will work as well for you and not pose more side effects.
It may also be helpful to ask your pharmacist if they have some tips to help make the medication more affordable for you. Assistance may be available through discount cards, drug company patient assistance programs, other healthcare companies that provide prescription drugs, or patient support programs.
You can find out what your out-of-pocket costs will be for a drug or service by asking your insurance company. If you are using a doctor or pharmacy that is not in your insurer’s network, it is particularly important that you ask your insurer what your cost share will be ahead of time.