Prior Authorizations for Medications
What is a Prior Authorization?
A prior authorization, often referred to as a PA, is a method of checks and balances for your insurance company to review a medication, device, or procedure before your insurance plan will cover the cost. Insurance companies want to make sure the medication or procedure is medically necessary and appropriate. Every insurance company is different, so while a medication may be covered on a previous plan, a new one can throw things off balance.
Sometimes, these authorizations can take some time. The average turnaround time for medication authorizations is approximately 3-5 business days, but the time can vary. iTrust Wellness Group staff has the ability to submit a PA to your insurance company for review electronically, so typically the process can be expedited through our practice.
If your medication is not authorized, it may cost you more money out of pocket and it may not be covered.
What Drugs need a Prior Authorization?
Here at iTrust Wellness Group, we use medications that are both brand named and generic. There are a lot of psychiatric medications that do not yet have a generic, so they are more costly to your insurance company. Many of the drugs in our system need a PA, such as Auvelity, Rexulti, Belsomra, Vyvanse, Caplyta, Vraylar, and more.
Your insurance company has a list that dictates what drugs will and will not require a PA, known as a formulary. This can include not only the type of medication, but also the quantity and days' supply. PAs are also often used for drugs with dangerous (but potential) side effects, drugs that are harmful when combined with other drugs, drugs used for specific health conditions, drugs that are often misused or abused, and/or when there is a less expensive drug that the insurance company believes could work better.
iTrust Wellness Group providers will always operate with the lens of excellent psychopharmacology and believes in prescribing medications tailored to the patient, not based around insurance companies' expectations.
What to do if your prescription needs a PA: Oftentimes, pharmacies who receive the prescription will notify the prescribing office that the medication requires a PA based on their communication with your insurance company. However, if you want to be proactive, you can easily call your insurance company or go to their website and see the formulary if your treatment choice needs a PA.
Here at iTrust, we take care of most PAs in our office through our medical staff. Our staff works diligently to ensure these are approved but cannot control what the insurance company decides. If we cannot get a drug approved, we may switch to a different option or attempt to appeal the denial and overturn the decision of your insurance company not to provide coverage.
Some insurance companies will authorize short term supplies of a prescription while a PA is in process, so it is okay to ask for this from your insurance. If you run into issues with coverage at the pharmacy, reach out to our office for assistance to see if a PA may be necessary so that we can help you get the medication covered.
While the prior authorization process is not ideal, they are a routine requirement for a variety of medications when using insurance. iTrust Wellness Group providers and staff are committed to getting you the medication that will best help you through your mental health journey and will complete all prior authorizations in a timely manner. While insurance companies ultimately decide, we will be your advocates through every step of the process in order to make your treatment successful and beneficial.
BCBS (Ed.). (n.d.). Why do I need prior authorization for a prescription drug? Why do I need prescription prior authorization? Retrieved March 22, 2023, from https://www.bcbsm.com/index/health-insurance-help/faqs/plan-types/pharmacy/why-do-i-need-prior-authorization-for-prescription-drug.html
What is prior authorization? Cigna. (n.d.). Retrieved March 22, 2023, from https://www.cigna.com/knowledge-center/what-is-prior-authorization