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What is Prior Authorization in Pharmacy: Med Overview

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Step into the world of ‘What is Prior Authorization in Pharmacy: Med Overview’ with Portiva. We’re here to simplify the process, always putting your well-being first. Together, let’s unravel the complexities of prior authorization, making those insurance moments hassle-free for your healthcare. Count on us to equip you with the insights for a smoother journey in your health and well-being.

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require prior authorization prescription drugPrior authorization in pharmacy means obtaining prior approval from your health insurer to use a certain medication for treating your medical illness. You must inform your health insurance company by submitting a request form to ensure your healthcare plan covers your medical expenses under the terms of the pharmacy benefit plan.

If you submit an urgent request, your insurer will respond within 72 hours. On the other hand, if you submit a normal prior authorization request, it may take 8-10 days for the health insurance provider to review your request and decide.

Health insurance companies demand prior authorization to ensure the prescribed pharmaceutical drug is obligatory and within the health plan guidelines of the insurance company.

How Prior Authorization Process Work?

Prior authorization begins when your healthcare provider submits a prior approval request to your health insurer for approval to provide you with a certain medication to cure your illness. The health insurance provider reviews your prior authorization request and reverts with either of the following responses.

  • Approve your prior authorization request.
  • Denies your prior authorization request.
  • Ask questions for clarity.
  • Suggest low-cost, effective alternatives.

The health insurance company’s response depends on the information and clinical data your healthcare provider shares. The insurer forwards your request to their team of clinical pharmacists to check if the prescribed drug is medically necessary to cure your illness before making their decision.

However, if they refuse to approve your prior authorization request for a certain medication, you can request a health insurance provider to review their decision.

Why Your Health Insurance Provider Need Prior Authorization?

Your health insurance company requires prior authorization for a certain pharmaceutical drug to review your request before approving the prescribed medication.

For instance, your healthcare provider may have prescribed a high-priced pharmaceutical drug. Prior authorization lets your health insurance provider assess your prior approval request and revert with a low-cost, effective alternative to cure your illness.

What Types of Pharmaceutical Drugs Require Prior Authorization Requests?

medications a hand writing on a sheetSeveral types of medication require prior authorization approval from your health insurer. Following are some pharmaceutical drugs that require prior authorization.

  • Pharmaceutical drugs with dangerous side effects.
  • Medication injurious to health when combined with other medicine.
  • Pharmaceutical drugs are used only for certain health conditions.
  • Medications that are often misused or abused.
  • Expensive pharmaceutical drugs.

What is a Pharmacy Benefit Manager (PBM)?

Pharmacy Benefit Manager (PBM) is the company that handles prior authorization requests and provides pharmaceutical drugs in place of your health plan. Blue Cross Blue Shield health plans have their PBMs to facilitate people requiring medication. If you want to know more about your pharmacy benefits, you can contact your health insurance provider.

How do you obtain prior authorization for a pharmaceutical drug?

If you require prior authorization for a certain pharmaceutical drug, you must obtain prior approval from your health insurance provider before you use it to cure your illness.Because if you don’t submit a request, your health insurer won’t pay for your medication, and you’ll need to pay for your pharmaceutical drugs on your own.

Below are some helpful tips to guide you to obtain prior authorization for a prescription drug.

Speak to the Decision-Maker

Your health insurance company may require a prior authorization request, but it’s not certainly them who makes the decision. Many health insurance providers prefer in-house prior authorizations, while a few insurers outsource such tasks to pharmacy benefits management companies.

Your health insurance provider may consult a pharmacy benefits company to review your request and decide whether to approve your prior approval request for a prescription drug.

However, if you still need to know which specific company will handle your prior authorization request, don’t worry; your health insurer will let you know. Don’t depend on your health insurance company to decide whether to approve or deny your prior authorization request. Hold your words till you get a chance to speak to the decision-maker.

Read the Clinical Guidelines

See the clinical guidelines based on which the health insurance company reviewers will decide. If you need to check if the guidelines are available online, you can call your health insurance provider to let you know. If the guidelines are accessible virtually, your health insurer will forward them to you.

Reading the clinical guidelines will let you fill in the exact information your health insurance provider will need to review your request. You’ll get approval within no time if your pharmaceutical drug requirement is within the health plan guidelines.

Submit In-depth and Accurate Information

Ensure the clinical data and information you submit to your health insurance provider are correct and thorough. If the entered information is complete, you may avoid a delay against your prior approval request. In addition, if the pharmaceutical drug details you submitted are accurate, your prior authorization request may be accepted. Thus, it’s crucial to fill out the request form carefully and review all the information before you submit your prior authorization request to the health insurance company.

Talk to Your Health Insurance Provider If They Refuse Your Request

prior approval doctor talking to a patientSpeak to your healthcare provider to get to know the reason behind the rejection of your prior authorization request. Also, you can call your health insurer to better understand why they denied your request for prescribed medication.

Ask your health insurance provider to share the reason in easy words. You may be able to fix the issue and get an approval.

For instance, your healthcare provider may have prescribed a costly drug for curing your injury, which the insurer believes isn’t that medically necessary. However, if you can learn about this, you can ask your healthcare provider to share why they prescribed this medication and how it can cure your injury. Your health insurance provider may approve your request if it qualifies your health plan criteria.

Recheck your submitted request to find out if you forgot to share certain information in your request form. By revisiting your request, you’ll be able to identify the gap and fix it.

Make Sure Your Health Insurance Company Follows the Guidelines

It’s crucial to ensure that your health insurance provider complies with the state regulations related to prior authorization.

For instance, your health insurance company can’t ask for prior authorization to determine whether prescription drugs for mental health abuse are necessary if they don’t have a similar protocol for medication.

Also, you can understand the guidelines with the assistance of your healthcare provider, as they have a decent understanding of such prior authorization rules.

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How do I know if My Pharmaceutical Drug Require Prior Authorization?

health insurance company holding medicationIt is easier to discover if your pharmaceutical drug will require prior authorization once your pharmacy claims to your health insurer. The pharmacy may receive a refusal from your health insurance company stating that they require more information to analyze your prior approval request.

The pharmacy will contact your healthcare provider for more information and inform you that the prescribed drug can only be covered on your health plan once your health insurance company approves your prior authorization request.

However, you can call your health insurer if you are unsure if your medication requires prior authorization.

How Much Time Does A Prior Authorization Take?

Your prior authorization request may require a week or more than a month to get approved. The time this process will take depends on the complexity of your prescribed drug. The medical information sent to the health insurance company by your healthcare provider will play an essential role in extending or shortening the process of your prior approval request.

How to Fasten Up Prior Authorization Process?

You can speed up your prior approval process by contacting your health insurance provider and informing them that you require prescribed pharmaceutical drugs on a prior basis. Also, you can maintain a record of all the correspondence between your health insurer and healthcare provider. 

However, to speed up your prior authorization request, you need to build a robust tracking system to ensure you remain current on all communication between your healthcare provider and your health insurance company.

Understanding the Prior Authorization Process:

The prior authorization process is crucial in accessing certain medications that healthcare providers prescribe. It involves seeking approval from health insurers to ensure coverage under the terms of the pharmacy benefit plan. The American Medical Association acknowledges the significance of this process in safeguarding patient health and controlling the use of potentially harmful or abused drugs.

Navigating Certain Medications Through Prior Authorizations:

Certain medications, known for their potential risks or high costs, often require prior authorizations from health insurance companies. These requests are carefully reviewed to determine medical necessity and adherence to health plan guidelines. Ensuring compliance with the American Medical Association’s standards, this process aims to mitigate patient harm and promote the responsible use of pharmaceuticals.

Challenges and Solutions in Prior Authorizations for Certain Medications:

time consuming coworkers with papersThe process can be intricate and time-consuming despite the importance of prior authorizations in controlling access to certain medications. Patients may face delays, and healthcare providers navigate complex guidelines set by health insurers. Addressing patient harm concerns and preventing the misuse of abused drugs remain key priorities in refining the prior authorization system.

As stakeholders work towards a smoother process, collaboration between healthcare providers, insurers, and patients is essential to balance access to necessary medications and safeguard patient well-being.


In summary, handling the prior authorization process within your insurance plan is vital, particularly when dealing with potentially expensive medications. Understanding the insurer’s clinical guidelines and communicating proactively can expedite approvals. In cases of denial, open dialogue with healthcare providers and insurers is crucial for resolving issues.

Insurers often suggest lower-cost alternatives, prioritizing effective treatment while considering financial implications. Taking proactive steps, like informing insurers in advance and maintaining clear communication records, contribute to a smoother process. Collaborative efforts among patients, healthcare providers, and insurers strike a balance between accessing necessary medications and considering lower-cost alternatives, ensuring both health and financial well-being.

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