Prior Authorization Prescriptions and More: Overcoming Insurance Problems at the Pharmacy

There's nothing more aggravating when you get a prescription filled than to have an insurance problem arise. It's unnerving to be told that your medication is not covered by your insurance, and it's often hard to understand why this problem is occurring.

The first step to getting your insurance issue resolved is understanding the issue itself. There are several reasons why an insurance company may deny you coverage for any certain medication or prescription.

a. Prior Authorization.
Essentially, prior authorization is your prescription insurance company's way of keeping costs down by making sure that your doctor has tried a less expensive therapy first, or that the medication your doctor prescribed is medically necessary.

If your prescription requires prior authorization ("prior auth" in pharmacy-speak), the pharmacy will contact your doctor to inform him or her that prior authorization is required. Your doctor's office knows what to do and will contact your insurance company for you. The pharmacy will continue to attempt to bill your insurance company each day for the medication. The prior authorization process usually takes 3 to 5 business days, sometimes more and seldom less.

It's important to remember that prior authorization may only last for a short period of time, and rarely lasts more than six months. After it expires, the process between your doctor and insurance company must be repeated.

b. Drug not covered.
Sometimes your medications are simply not covered by your insurance provider. The medication may not be on your insurance company's list of drugs that they prefer (often called a "formulary"). If this happens, ask your pharmacist or technician to contact your doctor for a "preferred therapy." Your doctor will be able to authorize the pharmacy to use a different medication in place of the prescribed one over the phone.