Patient Advocate Foundation (PAF) is a national 501 (c)(3) non-profit organization which provides case management services and financial aid to Americans with chronic, life threatening and debilitating illnesses.
Know Your Drug Formulary Restrictions: Prior Authorization
You cannot afford to overlook the restrictions and limitations section of your drug formulary. These limiting conditions are in place to help you and your drug insurance company save as much money as possible.
One of these restrictions is prior authorization (sometimes seen as PA on drug formularies). Prior authorization requires that your doctor obtain approval from your health insurance plan before your plan will allow access to certain medications. If they do not seek approval before prescribing you these restricted drugs, your plan will not cover the medication, and the pharmacy will want 100% of the cost in order to fill the order.
What kinds of drugs are typically subjected to prior authorization?
Brand-name medications that are available as generic drugs
Drugs also used for cosmetic reasons
Drugs that treat non-life threatening conditions
Drugs that are harmful when combined with other drugs
Drugs that can be abused or misused
If you notice a drug you have been prescribed requires prior authorization, inform your doctor immediately so they can contact your insurance company and begin the process.
More often than not, you will not know that a drug requires prior authorization until your pharmacist rejects your claim or you are asked to pay full price for your medication. In this case your pharmacist will usually contact your doctor and let them know that your medication requires prior authorization. What you should do now is contact your doctor to find out how long you can expect the process to take. You should also contact your health insurance provider to find out if there is anything extra they require of you. Some providers ask the patient to fill out some paperwork or sign some forms.
If your claim is not approved, contact your insurance company to find out why, and discuss alternative options with your doctor. If you do decide to pick up your prescription without prior authorization or before the process has been completed, you will have to pay full price for your medication.