Prior Authorization

Sometimes, when your doctor sends in a prescription for you, you'll be told by your pharmacist that the medicine can't be filled or is not covered. They may tell you a Prior Authorization (called a PA) is required. A PA is a means to control pharmaceutical costs by attempting to limit or control your access to certain medications.  Firstly, know that a prescription authored by your doctor can ALWAYS be filled, the issue is one of what your insurance covers; not availability or appropriateness. If you are told by the pharmacist that a PA is needed, we ask that you collect from the pharmacist any and all insurance forms required by your insurer.  Since PA faxes can be lost or duplicated, we ask that our patients ensure any required forms are brought to us; we can not guarantee that we will respond to pharmacy requests for PA's. 

Before accepting that a PA is needed, first ask the pharmacist if he is aware of any similar drugs that would not require a PA. Sometimes this information is available, sometime it is not.  If the pharmacy is not aware of covered medicines, contact your insurer.  As their policy holder, you should be able to get a list of preferred drugs (called a "formulary").  Each plan and employer can have different formularies and they can change without notice. We are not able to keep up with multiple lists of what drugs are covered or not.  You can secure your individual plan formulary and, armed with this knowledge, you can call us and request the medicine change.  If your physician agrees, we will send in the new prescription.  This is the simplest way around the PA.

If an appropriate alternative is not available, we'll have to follow the PA process. Again, we ask you to be involved to assure that both your insurer and we serve your needs as timely as possible.  By involving you early on, we can ensure we have all the information we need from you, including confirming your RX insurance and a list of acceptable alternatives to the non-covered drug.    Sometimes your insurer stipulates the trial of a preferred drug first.  We will likely comply with that stipulation and prescribe the preferred drug.  If you have special need for the originally prescribed drug, you can always get the original prescription filled - at your own cost.  If we must submit medical chart support to your insurer for the non-covered drug, we will do so and offer you a copy of all correspondence.  We will update you via  your patient portal. 

We dislike delaying your treatment in this way, but this process is a result of your insurer's policies.  We have tried to handle PA's without your involvement, and very often find communication regarding PA's with insurers and third parties is prone to delays.  And we feel you are not always fully informed of the process.  We hope that your involvement will hasten the completion of those PA's that are required.