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Prior Authorization Prescription: Doctor's Essential Manual

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Table of Contents

prior authorization approval of a medical necessityPrior authorization is the approval of coverage if that patient’s health insurance company plan doesn’t cover the expensive treatments or provide the medical necessity for various reasons.

Prior authorization involves the healthcare provider, Insurance company, patient, and often pharmacist for Prior Authorization approval.

If the prescription is billed through insurance, prior authorization is only necessary. However, if one is uninsured or chooses to pay in cash, there is no need to be concerned about obtaining prior permission.

Before the plan can provide coverage, it is necessary to review certain medications. The aim is to determine if the medication is medically required and suitable for the individual’s situation. Failure to obtain a prior authorization request may result in increased costs for the medication or the possibility of it not being covered by the plan.

The plans often create standards for this review, using medical guidelines, cost, utilization, and other information. Different insurance companies have different plans, clinical guidelines, and rules for obtaining approval for prior authorization.

For example, when patients come to the pharmacy to fill their prescriptions, clinical pharmacists are sometimes told that they cannot take any medication unless the health insurance company approves its cover cost and use. Some prescriptions require authorization from the insurance company, so patients may have to wait a long time–from days up through months for a test or medical procedure to be scheduled.

We’ll first discuss the kind of drug requiring a prior authorization request form.

Overview Of Prior Authorization Process:

Here is an overview of the prior authorization process for prescriptions.

relevant information doctor explaining to a patientFirstly, A healthcare provider diagnoses a medical condition and prescribes a medication for the patient.

Then, before the patient can get the medication, the healthcare provider or staff checks with the patient’s insurance company and health plan to determine the coverage details and potential excessive costs.

The healthcare provider must request prior authorization if the insurance company needs approval before covering the prescribed medicine. It usually includes filling out a particular form given by the insurance company.

Then, the insurance company reviews the completed prior authorization request, which includes any supporting documentation like medical records or clinical notes.

The insurance company examines the prior authorization request to determine if the prescribed medication is medically necessary, safe, and cost-effective. Pharmacists or other healthcare professionals typically conduct this part of the process the insurance company employs.

After days, weeks, or perhaps months after the review process, the insurance company either approves or denies the prior authorization request. If approved, the patient can proceed to obtain the prescribed medication. If denied, alternative medications or appeal processes may be explored.

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Board Certified Family Medicine Physician

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Type Of Medications That Need Prior Authorization Process:

Many different types of medications require prior authorization process requests in pharmacies. The prescriptions that usually need prior authorizations can differ depending on the rules of particular health insurance plans.

The following are the common medications that require prior authorizations.

Specific Medication:

Specialty medications, commonly prescribed for complicated or uncommon illnesses, need prior approval because they are expensive. Insurance companies thoroughly evaluate these drugs, including biological or targeted therapies, to ensure they are medically necessary and cost-effective.

Step Therapy:

treatment guidelines hand holding tablet of drug and explain to patientStep Therapy is a method used by insurance plans where patients must first try to show that cheaper or different medications don’t work before they can get permission from the pharmacy for pricier or more advanced treatments. This method mainly manages healthcare expenses while guaranteeing patients suitable and affordable treatment.

Patients start with the first, usually cheaper, treatment option that suits their condition. If the initial treatment doesn’t work or causes unwanted effects, the patient can move on to the next level of therapy, which might include a more advanced or expensive medication.

The drawback of step therapy is that it typically requires prior authorization at each stage. This means that the healthcare provider needs to record how the patient responds to the current treatment before moving on to the next step.

It is important to consider patients’ needs while maintaining the objectives of managing costs and promoting the use of lower-cost options.

High Costs And High Usage:

High-cost and high-usage drugs are categorized as such due to their expensive nature and frequent use, which are mainly brought from pharmacies. In comparison to other options, these medications often come with a higher price tag, which can raise concerns about excessive utilization.

This is mainly because insurance plans might require prior authorization for these drugs. The insurance company thoroughly reviews plan documents and relevant information from healthcare providers and pharmacies, like patients’ history and access to personal medical files.

With the help of pharmacy, insurance plans aim to find a middle ground between granting access to essential treatments and controlling healthcare costs by using prior authorization for these medications.

Alternative Options:

There might be some medication that might be very expensive for treatment or might not be involved in the patient’s health insurance plan. The request would take some time to approve if prior authorizations are required for the medication.

But if there is a lower-cost alternative in the pharmacy for those types of medication, the health insurance company can cover the patient’s medication for the treatment guidelines.

Biological Medication And Infused Medication:

Biologic or biological medicines are medicines made from living organisms or created through biotechnological methods. These medicines, including proteins and antibodies for complex or long-term diseases, take longer.

Inversely, infused medications go directly into the blood by intravenous (IV) drip. The prior authorization method provides a controlled, standardized supply of the medication. Infused medicines come in many forms- biologicals or chemotherapy drugs and specific antibiotics. It is mainly available through prior authorization.

Controlled Substance:

abused drugs a man overdosed with medicineControlled substances are drugs that have a greater likelihood of being abused or leading to addiction. Drugs of abuse and another class of drugs that the government regulates with strict rules are included.

Because these substances- opioids, stimulants, and sedatives are easily misused, their use is closely monitored. Healthcare providers and pharmacies must follow specific rules when prescribing and dispensing controlled substances.

These medications are available only on prior authorization, and they must be continually monitored to avoid abuse.

Healthcare heavily relies on prescription drugs as they provide vital remedies for multiple conditions. Yet, the mishandling of specific medications, particularly abused drugs prone to misuse, such as opioids and stimulants, poses significant obstacles.

Striking a balance that guarantees the availability of necessary prescriptions while preventing abuse is paramount. Drug exploitation complexities accompanied by potential risks demand human monitoring and expertise capability in writing technologies.

Why is a Prior Authorization Prescription Necessary:

There are many reasons as to why prior authorization is essential. The most important one is that prior approval helps find an alternative medication. If a prescriber gives an expensive medication, then there might be an alternative one available with the same formula or a very similar function to the expensive one.

Plus, insurance companies use prior authorization to control healthcare costs. By requiring authorization before handing out specific medications, they can guarantee that costly medications are prescribed mainly when medically necessary.

Not only that, using a prior authorization procedure guarantees that the selected treatment of the patient is safe and effective for the particular medical condition. We are reducing the risk of significant side effects.

Certain medications have a greater risk of misuse or overuse. However, prior authorization is one of the methods to supervise and regulate the availability of these medications, thereby minimizing the chances of abuse and misuse.

When step therapy is necessary, prior authorization for prescription guarantees that patients follow a logical order of treatments; they begin with lower-cost options and only move on to more expensive alternatives if needed.


Prior authorization in prescription plays a vital role in obtaining medication from a pharmacy if the patient’s insurance plan doesn’t cover it. The process of prior authorizations for prescription begins with the healthcare provider prescribing the medication. Then, the medication is checked to see if the health care plan covers it. If not, a prior authorization request is made to the health insurance company. After a review, they make a decision.

Different types of medication require prior authorizations.

While beneficial, it is intended to achieve cost savings and ensure appropriate medication use, it can sometimes delay patients’ access to essential treatments. Efforts are ongoing to improve the efficiency of the prior authorization process in healthcare with technology.

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