Medical preauthorization is a decision by your health insurer that tells you about necessary health care service, treatment plan, a prescription drug. It is also called prior authorization, prior approval or precertification. Before a patient receives a particular prescription medication, the doctor is required to submit the information to the insurance company about the patient’s specific need for the medication. Once the insurance company has received the doctor’s justification, they will approve the medication, and the patient can receive his or her treatment.

Purpose of pre-authorization in health insurance contains health care spending. These companies apply procedures to certain high-cost medications to ensure that a prescription is medically necessary before agreeing to pay for it. Health insurance companies do pre-authorization of medicines in order to keep healthcare cost of the customers low. It also ensures that your medication is necessary, up-to-date, economically purchasable, and isn’t being duplicated. Health insurance companies can afford to provide expensive medications but to those who truly need it.

When should the prior authorization process begin?

Every Health Insurance company has its clinical pharmacists and medical doctors who are well-trained and experienced in reviewing prior authorizations.

Prior authorization is required when you need a complex treatment or prescription. You should first ask the doctor if a prescription medication will require prior authorization or not. If it requires, then your doctor will start the prior authorization process.  It is up to the company to either approve or deny the authorization request. There is no prior authorization required if you have an emergency situation and you need medication.

Working of Pre Authorization

Pre-authorizations for prescript drugs are handled from your doctor’s office and your health insurance company. Your insurance company contacts you with the results to let you know if your drug coverage has been approved or denied. If you are not happy with the pre-authorization decision, then you can ask for the decision or tell your doctor to change prescription which is less costly but the same effective. Sometimes, your health insurance company may recommend you try an alternative medication that is less costly, but equally effective before your doctor prescription.

Pre-authorization works like this:

  • Step 1: Your pharmacy will contact if your doctor did not obtain prior authorization from the insurance company when prescribing a medication.
  • Step 2: The physician will then contact the insurance company and submit a formal authorization request.
  • Step 3: Your insurance provider may fill and sign some forms.
  • Step 4: The insurance company will alert the pharmacy once they have approved or denied the request.

What types of medications typically need to be approved?

  • The medicines which may be unsafe when combined with other medications
  • Medicines only used for certain health conditions
  • Drugs which are often misused or abused
  • Drugs often used for cosmetic purposes

Pre-authorization medication can take some days to process. Within a week, you can call your pharmacy to see if the request is approved or not. If it is not, then you can call your health insurance company to get the reason for delayed/ denied authorization.

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