Prior Authorizations

What are Prior Authorizations (also known as PA's, pre-certification, or prior approval)?

Some healthcare services like prescription drugs, imaging studies, lab tests, or durable medical equipment can be extremely expensive.  In many ways, the prior authorization process is a cost-minimizing technique used by insurance companies to determine the medical necessity of high-cost treatments.  Insurance companies also use prior authorizations to determine the appropriateness of prescribed treatments when other evidence-based treatments are available that may be less invasive or have less potential side effects. 

According Blue Cross Blue Shield, prescription drug prior authorizations are required for:

Drugs that have dangerous side effects

Drugs that are harmful when combined with other drugs
Drugs that you should use only for certain health conditions
Drugs that are often misused or abused
Drugs that a doctor prescribes when less expensive drugs might work better

If a prior authorization is required for a prescription drug, the pharmacy will be the first to know.  Sometimes the pharmacist is able to identify an alternative or generic prescription where there is no need for a prior authorization.  In all cases, the the pharmacy will send our office notification.  Our staff of clinicians will review the pharmacy notification.  If a suitable alternative medication is available without a prior authorization, the clinician may switch the drug to the insurance or pharmacist recommendation. 

In scenarios where there are no alternatives or generic prescriptions available, a prior authorization is started by our office.  When a prior authorization is initiated, it can take the insurance anywhere from 2-14 days to approve or deny the request.  Once the insurance determines the outcome of a prior authorization request, the pharmacy and patient will receive written notification of the approval or denial.  It is important to know that the decision to approve or deny a prescription medication or therapy is made soley by the insurance company.  Patients always have the option to pay cash, or out-of-pocket, for medications or drug therapies, but that can be very costly.  

If you have any questions about our prior authorization process, please contact our office at (530)885-3951.  Your insurance company will be able to give you more information on the prior authorization process as well as explain the subject in more depth.  Your insurance may also be able to notify you of what benefits you have and what your specific plan will or will cover.  Being an informed patient is the best way to actively participate in your care.