The below is from an insurance company that explains it. For patients with diabetes, this happens all the time as most medications are new and require prior authorization. This creates the need for pharmacists and physicians to work together. At EPC, we are working to create this environment where pharmacists and physicians work side by side to avoid these prior authorizations.
To avoid delay in medication and to lower cost and save time, we recommend that you use Privia pharmacy as we can easily communicate with the pharmacist and avoid and manage these prior authorizations in a timely manner.
(below from a national insurance company).
What is prior authorization?
This means we need to review some medications before your plan will cover them. We want to know if the medication is medically necessary and appropriate for your situation.
If you don’t get prior authorization, a medication may cost you more, or we may not cover it.
If you file an urgent request, we will have a decision provided in 72 hours or less. For an urgent review of a non-covered drug, one not on your drug list, we will have a decision in 24 hours or less. A standard request may take up to 15 days for us to make a decision.
What kinds of drugs need prior authorization?
- Drugs that have dangerous side effects
- Drugs that are harmful when combined with other drugs
- Drugs that you should use only for certain health conditions
- Drugs that are often misused or abused
- Drugs that a doctor prescribes when less expensive drugs might work better
How do I find out if my medication needs prior authorization?
We cover certain drugs under the pharmacy part of your insurance and others under the medical part of your insurance.
What should I do if my prescription needs prior authorization?
If your drug needs approval, either you or your pharmacist will need to let your doctor know. Your doctor might switch you to another drug that doesn’t need prior approval.