Why do some Prescription drugs require Prior Authorisation?

Have you ever walked into the pharmacy and been told that your prescription requires a prior authorisation, but your doctor prescribed something for you, and you brought in your prescription, shouldn’t that be enough? What exactly is a prior authorisation, and why can’t you just pick up your prescription?

Your insurance company may ask for prior authorization before agreeing to cover the cost of certain medications. Understanding how prior authorization works and how to request it can help you to reduce delays in receiving your medication.

Here is what you need to know about the process of prior authorisations.

What exactly is a prior authorisation?

Prior authorisation is a process used to determine if your insurance company will cover a prescribed procedure, service, or medication. To authorise certain prescriptions, your insurance company will request that your prescribing doctor provide more information about your medical needs. This information helps determine if your insurance company will provide coverage for the cost of your medication.

In most cases, your pharmacist will tell you if you need prior authorization when you fill your prescription. Without prior authorization, you will be required to pay the full cost of the medication or treatment.

Types of prescriptions generally require prior authorsation

Insurance companies want to review prescriptions before paying for them in a variety of situations, including:

• Brand name drugs prescribed when a generic is available.
• Drugs that is intended for certain age groups or conditions only.
• Drugs used only for cosmetic reasons.
• Drugs that are not preventative, or used to treat non-life threatening conditions.
• Drugs that may have adverse health effects, including higher than standard doses, or possible interactions, abuse, or misuse.
• Drugs that are not covered by your insurance but deemed medically necessary by your provider

In many cases, prior authorisations are intended to be a control to ensure drug use is appropriate and the most clinical and cost-effective therapy is being used.

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What should you expect if you need a prior authorisation?

In most cases, the pharmacy will notify your healthcare provider, who will provide the necessary information to the insurance company. The insurance company will then decide whether to accept or deny coverage on the medicine.

Since the process takes several steps, it may take some time before the pharmacy has a response. You can usually expect a delay of at least 1 to 2 days, although sometimes it can take longer. If approved, prior authorizations are only valid for a set amount of time and may require periodic re-approval.

What do you do if your prior authorisation is denied?

If your prior authorisation is denied, your insurance won’t cover the prescription. At this point, you may want to talk to your pharmacist and healthcare provider about alternatives that would be covered. You can also decide to pay out of pocket, and compare discount cards, cash prices, and assistance programs to determine what works best for you.