If you have ever been told by your pharmacy that your new medicine needs a “Prior Auth” before they can fill it, you may have felt confused and frustrated.
Here’s a summary of a somewhat complex process.
A prior authorization (prior auth) is a requirement by your health insurance plan to obtain approval for specified medical services such as certain prescription medications, diagnostic imaging, physical therapy and medical equipment. Without this approval, the medical service will not be covered by your insurance. And sometimes prior auth requests are denied by the insurance company.
DMC handles prior auths for our patients – usually for new prescriptions and imaging. We do not handle prior auths for physical therapy or for most durable medical equipment.
Following is an example of the typical prior auth process for medication (but please note that the process varies from patient to patient and can be different for each person/situation).
- Your provider prescribes a new, brand name medication for you
- The prescription is sent to the pharmacy
- The pharmacy runs your claim through your insurance and the claim is rejected because prior auth is needed
- The pharmacy contacts DMC to let us know
- DMC contacts your insurance on your behalf to request the prior auth (or we may need to call you to gather for more information)
- When DMC receives approval of your prior auth, we provide a courtesy call to the pharmacy and the patient. If the prior auth is denied, we work with your DMC provider and you to appeal the denial or to find an alternative medication for you that your insurance will cover
This process with your insurance company can sometimes take days to complete. Please be assured that DMC’s prior auth team is working hard for you behind the scenes to help you get the medicine or care that you need as quickly as they can.
What might cause my insurance company to require a prior auth?
- Formulary change: when your plan decides that there are alternative medications they will cover
- A high-tier medication: your plan may offer to cover a lower tier if one is available
- Exclusions: when your insurance company no longer covers the medication your provider prescribes
- Quantity: when your insurance plan will only allow a certain quantity of medication – additional quantity may only be covered if considered medically necessary by your plan
What are some reasons a prior auth may be rejected?
- Plan requires the patient to have a trial and failure of their preferred and covered medications first
- If a medication is excluded, the plan no longer covers that medication
- Medication quantity or dose exceeds the max allowed through your health plan
How can I assist in the prior auth process?
- You can call the member services number listed on your insurance card or go to their website to confirm which medications are covered without a prior auth on your health plan
- If it has been more than 3 days since your medication claim rejected at the pharmacy, please call DMC at 603-537-1300 and ask to speak with our prior auth department. Please be sure to have your current pharmacy benefits available (or know who your pharmacy benefits go through) and know the name of the medication that rejected at the pharmacy
- Please be patient. We work with your insurance company and progress can be limited by their processes and guidelines
Once a prior auth has been completed and denied, what is the appeal process?
- Patient or DMC provider can request an appeal
- DMC Provider may need to provide “letter of medical necessity” to DMC’s prior auth department
- Letter goes to insurance company’s appeal department
- Appeal process begins – and can take 48 hours to 60 days with your health plan
- Insurance company sends final decision letter to DMC provider and patient
- Patient contacts provider to request new prescription (if needed)
Most insurance plans also require a prior authorization for high-end diagnostic imaging. Please contact your health plan directly for specific details.