WHY DOES INSURANCE WANT A PRIOR AUTHORIZATION?

Each insurance company has a drug formulary, or a list of prescription medications that it has approved and will help cover the cost for, with evidence to support why a medication is included or excluded from the list. This list is typically updated no less than every quarter, which ensures that pharmacy benefit managers (PBMs) are accounting for marketplace changes, new drug entrants, and changes to clinical guidelines.

As a patient, you can experience a pause in the prescription process when the medication you have been prescribed is not the appropriate first-line therapy, is not on the insurance's formulary, or is used improperly. The insurance company will then require a prior authorization (PA).

A PA is required from the prescriber to obtain pre-approval from the PBM before the medication can be dispensed. It must prove a medical necessity to justify why you cannot use a product on the formulary and/or ensure the product is being used according to the FDA indication. It may also be required if the medication has a high potential for misuse or abuse. PAs are usually good for one year before needing to be renewed.

These policies are in place to keep you safe, to be cost effective for the plan, and to ensure that medication utilization is clinically appropriate. Please understand that the pharmacy has no control over these guidelines.

While the prescriber is trying to get approval, you have only two options: wait for the physician to complete prior authorization or pay full cash price for the prescription (a.k.a. not use the prescription plan benefit).

The biggest takeaway from learning about these policies and procedures is understanding that they are in place to provide you with the best care possible. You may think that the cost is the only determining factor, but that is not the case. Each formulary has the evidence to support why a medication is included or excluded. It's not that the insurance just doesn't want to pay for it.