WPS Health Insurance Blog

Quick guide to prior authorizations

Posted by Marie Puissant

Apr 21, 2015 10:25:00 AM

prior authorizationsI’ve worked in the health insurance industry for several years and when my dad asks, I can definitely tell him a thing or two about deductibles, premiums, copayments, and the differences between various health plans.

So when he asked about prior authorizations, I thought I was being smart when I responded, “Oh, ya know, it’s when you have to get authorized by the health insurance company before getting certain medications, procedures, services, and/or treatments.”

Well sure, taken literally that is what it means. But really, what does that mean? This post focuses on prior authorizations of drugs; however the same guidelines generally apply to procedures and services. Talk to your insurance carrier and review your policy for those details.

There are hundreds of medications out there and more become available all the time. Prior authorizations of drugs make sure you get the right medication for your situation.

Here’s a handy little guide for some of the most commonly asked questions about prior authorizations for your medications. If your medicine needs a prior authorization, now you’ll know all about it.

What is a prior authorization? 

A prior authorization is an extra step taken by some insurance companies to review certain medications before your plan will cover it.    

What kinds of drugs need prior authorization?

  • Brand name drugs that have a generic alternative. A generic version typically has the same active ingredient as the brand name drug, but is available at a lower cost.
  • Drugs with dangerous side effects or ones that are harmful when combined with other drugs.
  • Drugs that are typically covered by an insurance company, but are being prescribed at a higher dose than normal.
  • Drugs that should only be used for certain health conditions.

How do you find out if your medication needs prior authorization?

It depends on your health insurance company and coverage. WPS covers certain drugs under the pharmacy part of your insurance coverage and other drugs under the medical part of your insurance. 

For the WPS Drug Prior Authorization List, click here.

For other companies, you’ll need to talk to your health care provider and your insurance carrier to see what’s covered and what prior authorizations you might need.

What should you do if your prescription needs prior authorization?

You’ll probably find out when you go to pick up your medication at the drugstore that you need a prior authorization. If your drug needs approval, you’ll need to let your doctor know so he/she can either switch you to a drug that doesn’t need approval or start the approval process.

The process typically includes submitting a request form (like this one from WPS). A review of your medication(s) is made and you’ll be notified within 15 days if the drug is approved or not. If you need the prescription immediately, you can purchase a small supply at the full retail price and seek authorization afterward. If the request is approved, you can submit for a reimbursement which may or may not be reimbursed from your insurance company or carrier.

Prior authorizations are there for your safety and to keep drug costs down. Talk to your doctor about your medications and ask about the prior authorization process for your health insurance company.

Have additional questions about prior authorizations? Let us know in the comments and we’ll follow up with you!

Topics: health insurance, Individuals & Families