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.

c. Drug class excluded.
This is an especially discouraging insurance problem at the pharmacy because you are usually left with few options. This means that your insurance company does not cover the particular medication you are trying to have filled, nor any medication that is used for the same purpose.

Common medications that may be denied coverage for drug class exclusion include: male enhancement drugs (i.e. – Viagra, Levitra, or Cialis), cosmetic therapies (i.e. – Retin-A Micro, Vaniq), hair growth drugs (i.e. – Propecia), and over-the-counter drugs (Prilosec, Colace, Benadryl).

d. Refill too soon.
If you are requesting to have the pharmacy fill a prescription when your insurance company has already paid for a days supply that is unused, you may be told that your refill is too soon. There are several reasons for this, and several possible outcomes.

If the refill is too soon because you’ve been taking more of a medication under the direction of your doctor, your pharmacy may contact your insurance company for a “change of therapy override.” Sometimes your insurance company may grant an override, but not always.

If you have been taking more of a medication than you should, especially if it is a pain medication or a medication that has the potential of being abused, your pharmacy will almost certainly deny you a refill, even if you offer to pay cash for it. This is to protect your health and safety.

If you are leaving on a trip or vacation, it is up to the discretion of your insurance provider whether or not they will allow you to receive a vacation supply. Ask your pharmacy to call and speak with a representative at your insurance company.

Now that you understand some of the most common problems with your prescriptions and insurance, you are ready to help resolve your issues quickly and easily.