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A quick lesson in the prior authorization process

Have you ever picked up a prescription at your local pharmacy and learned at the checkout counter that your insurance will not pay for it because you need a prior authorization? Nobody told you ahead of time and you are not sure where to go for help… If you have been in that situation, continue reading.

In this blog, SkinCare Physicians’ Prior Authorization Coordinators are shedding some light on the process of getting prior authorization.

SkinCare Physicians’ dermatologists prescribe thousands of prescriptions to patients in the Boston area each week, many of which require prior authorization.  Obtaining prior authorization for medications through prescription insurance benefits can get confusing for patients.  Here are the answers to 6 of the most common questions our Prior Authorization Coordinators get from patients.

1) What is prior authorization?

Prior authorization helps ensure the appropriate use of selected prescription drugs. The process is designed to prevent improper prescribing or use of certain drugs that may not be the best choice for a health condition. (Source: caremark.com)

2) How will I know if a prescription drug needs prior authorization (PA)?

Normally, either the physician or pharmacy will get in touch with SkinCare Physicians’ PA department to let coordinators know that the drug is not covered with a co-pay and perhaps would be if prior authorization were submitted.

If the PA department is not alerted or did not have time to inform the patients, he/she will go to the pharmacy and will be charged full price for the medication. At that time, the patient may still contact the PA department to inquire if the prior authorization process can be initiated.

Tip: Ask your doctors if the medication they prescribed might require prior authorization.

3) How can I facilitate the prior authorization process?

SkinCare Physicians’ prior authorization coordinators work diligently to understand what type of pharmacy benefits the patient has.  In many instances, the medical and pharmacy benefits come from separate plans with distinct insurance cards.  These cards, when scanned at the time of your visit, will speed up the process of learning about your pharmacy benefits and getting the prior authorization process started if need be.

Tip: Always bring your medical and pharmacy cards into the physician’s office to be scanned. 

4) What does the prior authorization coordinator do to help?

Prior authorization coordinators will either fill out and fax insurance forms on your behalf with information about why you are using the medication, or place phone calls to the prescription insurance companies asking for coverage with a co-pay.  Most of these forms are obtained through the prescription insurance web sites.  It usually takes 3-10 business days, (sometimes up to 14) for the insurance company to review these requests and let the PA department know the outcome.

Tip: Trust our PA coordinators and be patient.

5) What happens if my insurance denies covering the medication prescribed by my doctor?

Each insurance plan differs on what they do, or do not cover. If a drug is denied, we work with your physicians to prescribe a comparable medication that is affordable.

Tip: Be prepared to switch to a new drug.

6) What if I pay full cost for a medication, then prior authorization is obtained for that drug?

In most cases, you can get reimbursed for the cost of the prescription minus your co-pay.  You just need to notify the pharmacy that prior authorization went through your insurance and they will process the medication through their computer system and see that the claim is now approved through your prescription plan.

Tip: Keep in touch with our PA coordinators!

7) What medications prescribed by SkinCare Physicians do almost always require prior authorization?

Injectable medications prescribed for psoriasis, psoriasis arthritis and hidradenititis suppurative, such as Enbrel, Humira, Stelara, Remicade almost always require prior authorization and the use of a Specialty Pharmacy through which to obtain the drug.    The prior authorization process for these injectables can often take up to 14 business days to complete as more specific information and detail-oriented forms are required for coverage.

There is no doubt; the prior authorization process can be confusing, lengthy and frustrating at time for patients. However, the expert PA coordinators at SkinCare Physicians are here to help. If you know ahead of time that your prescribed drug requires prior authorization, if you bring your pharmacy card to your appointment, if you are patient and stay in touch with our coordinators, you will be pleasantly surprised. Our PA coordinators, Sandra and Lisa, can be reached directly at 617-383-8204.