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Not all plans provide the same level of coverage. If you have been prescribed a specialty drug that requires prior authorization you and your prescribing physician must complete a claim form that will be sent to your group insurance company for review.
Specialty drugs are often, but not always, drugs that cost $10,000 annually or more. They are often used to treatment complex conditions after other drugs have been tried without the desired result.
Prior authorization is used to ensure that the medication you have been prescribed is necessary and appropriate for your medical condition.
If you are prescribed a drug that requires prior authorization, you and your physician will complete a claim form for your insurance company to review. The claim form may be unique to the drug you have been prescribed. There are assistance services to help you complete the claim form and submit it and any other information required to your insurance company. You can expect a response in as little as 7-10 days, or it could take longer.
Contact your insurer and ask for a written explanation of why your claim was denied. Your doctor may need to send additional medical information about your condition. If your claim is denied a second time, there may be coverage from other sources or other medication alternatives for your condition. Ask your doctor for assistance.
The Simplify Prior Authorization initiative is an advocate for education about prior authorization (PA) and improvement in current prior authorization practices and processes. If your organization is interested in finding out more, getting involved, or in sponsorship of this important initiative, please contact us via the link below.
