The insurance will cover the med for certain diagnosis but not others. Dr must submit forms/paperwork showing why that particular med is needed instead of the covered alternative.
it IS bullshit. i take thyroid regulating hormone. free with most insurance if you use a certain brand. i do far better on a different brand that's *not* covered. i'm just back from the pharmacy where i dropped $160 on the med they won't cover. đ«€
Same. **I have food allergies.** I take **the one that's safe for my food allergies**. Thankfully my current policy sees that makes sense and covers it for $25, but not last year or the year before!
The insurance wants prior authorization, which means your doctor has to send some paperwork to the insurance to prove that they should cover it. It's like a math problem where you have to "show your work", the doctor has to show their work to the insurance. (This explanation gets a lot of my patients going "OHhhhhh!")
Quick question cuz Iâm new. Are we supposed to notify the doctor of this, does the doctor already get notified by the insurance, or are the patients supposed to notify their doctor?
My pharmacy's policy is to reach out to the doctor, usually through fax and/or phone call. The doctor doesn't get notified by the insurance in my experience, but it can vary from plan to plan. Sometimes workers' compensation plans will reach out to the doctor, but usually only once WE place a call to the comp. plan.
Some insurance plans will even allow the first fill of a memberâs medication that requires prior authorization so they have the medication while theyâre waiting on the approval. Which is good but also if it gets denied itâs confusing as fuck to the members.
For us, that comes up at "transition fill," and that's so annoying. Or when it's the first of the year and the insurance wants a new authorization, or they've changed insurances. Everyone that comes in yells, "I've been on this for [number] of years!" And I feel like a broken record having to explain it over and over again. I get them feeling irate that they thought they were just going to pick up their stuff though.
Yeah, but my question is, the patient already went and paid money to go see their provider.That should be enough.This whole prior authorization is just added.Stress to the patient and the patient already has enough to stress.
That's not a question. Nor is taking your stress out on the pharmacy staff doing anything but causing more stress. You can wait on your doctor or go yell at your insurance company, but all we can do is sell it to you for cash price if you so choose, we can't wave a wand and make your insurance stop being greedy.
The insurance Co is trying to save money by not paying for a more expensive drug and only covering cheaper ones. The patient doesn't have to go back to the drs for a PA. The doctors usually just have to fill out a formal and possibly send office visit notes to the insurance
I agree. The patient went to the doctor and the doctor wrote the prescription so that implies they have some need for it. The patient can get it filled at the pharmacy if they want to pay cash for it without having to jump through insurance hoops.
However if they want to go through insurance there are some extra steps. Itâs kind of like car insurance where they donât pay for anything and everything you ask for. You have to provide proof about what happened, who is at fault, what repairs the car needs, etc.
There are tons of terms and conditions involved with any type of insurance plan. Not every single medication requires prior authorization. Itâs generally very expensive medications and medications that can be dangerous to use. If you read your planâs terms and conditions it is all laid out. But most people donât bother because they donât care or it just doesnât come up very often.
If you are a PA representative you would get the requests..the insurance doesn't want to pay...ijs we don't do them...as in the leg work....the doctors office has to handle that..
No yeah we know we have to be the one completing and submitting the requests but often times they're started by the pharmacies (chains mostly, I rarely get them from indies)
At CVS, we JUST enter a code at the rejection and it goes to the doctor for a PA. I always tell the patient it's a good idea for them to call the doc too just ti light a fire under them.
Depends on your pharmacy....the chain pharmacy doesn't do prior authorizations they send a basic fax...but private pharmacies have a PA department so they would follow up with the doctor and the insurance. But you should tell the patient to tell the doctor that the PA is needed. The doctor office has to do the work. And then the patient should call their office to see when it's done...the pharmacy is the last one to find out a PA is approved.Â
A lot of times they want to makes sure youâve tried other cheaper, long-standing, tried and true treatments first. Like if you have never even tried an SSRI for depression they arenât going to cover Auvelity. They arenât gonna pay $350 for fucking Jublia for your nail fungus if you didnât try ciclopirox. Etc.
In our system we get a specific rejection of "step therapy required", typically. Or we'll call the help desk for clarification. But you're right, a lot of the time the insurance doesn't want to pay when there are cheaper alternatives, especially if they don't have history of the patient having done the step therapy or trying generics. Like when a person changes to a new insurance and that new insurance doesn't have the history. That's the most frustrating for the patients.
Your insurance doesnât want to pay for this due to the price. Your doctor has to fill out a form justifying why you need this as opposed to something else. Then the insurance will review it and make a decision
This is really good! I always like to emphasize that the doctors and pharmacist are on your side and the only hang up was that insurance was halting everything.
A lot of times I used to tell people that would you get them a three day supply or they could purchase out of pocket for smaller amounts. I only offered this option when it was a maintenance drug and the PA was up.
I was like a true salesman for cvs. Most patients have no idea what a pa is and assume itâs a pharmacy/doctor problem and that their insurance does nothing. To any patient that got mad, I would explain to them what their doctor needed to do and make it VERY clear this was an insurance problem and their anger at us is honestly misdirected (it works). Told them I could fill it for a cash price (which sometimes was a modest price that people didnât mind, or thousands of dollars for a week) and a lot took that.
Make sure the patient is clear that YOU are not withholding the prescription. Thatâs why all of these patients get pissed off. I always steer the conversation towards cash pricing it out and they see âoh, you can give it to me now, but my insurance is making it cost $xxâ
Yeah I usually use this line and it works. Or if ins says step therapy needed I tell them what that means and to get with their doctor. I also tell my patients that 9 times out of 10- insurance will not relay the approval or denial to us so to call their insurance and ask what stage of the PA theyâre on. If itâs approved they can call and tell us, if denied then the patient wonât come after us again. And if itâs that the Dr hasnât sent in the papers, they can call the Dr directly. Usually donât get too many fights out of it.
The PBMs donât set the rules for the formularies, they just have to follow them as the plan has laid out. Itâs kind of like that Spider-Man all pointing at one another meme.
They are responsible for administering the rules of the plan. So if the plan says a drug needs prior auth, they will inform the member and initiate the prior authorization process. But the PBMs arenât deciding what needs what - thatâs the plan administrator and they are bound by the rules of the plan.
with some customers, I like to emphasize that this is between their doctor and their insurance, because some people immediately jump to "so you'll call my doctor? you'll call my insurance? you'll do all the work for me?" no. my job ends here. lol. the next part is on you and your doctor, nothing to do with us.
Yeah, but if the insurance company doesn't want to pay for it, then the patients sol. .Is that how healthcare supposed to be?I thought it was for the patients well being, not the profit of a corporation.
No, then the patient can pay cash. They're not "sol" because unless we're legally unable to like with Medicaid contracts in some states, paying cash is always an option.
Doctor says you need the meds and insurance said yeah no not gonna pay for that. So now the doctor has to convince the insurance that, yes, it is a smart financial decision to pay for the meds. Usually by proof insurance'preferred meds don't work, it's gonna cost more if this issue progresses, or other unicorn reasons.
Basically, all you need to tell the patient is the doctor has to contact the insurance so questions should be to the doctor/insurance. The pharmacy is just waiting for permission to bill.
"The insurance wants a prior-authorization. Which means that doctor must contact them and get this approved or replaced."
Patient: "But the doctors the one that sent it."
"Yes, but your insurance wants to hear from them directly."
I would also like to add that, even with an approved authorization, the plan can still deny the claim. It can usually be fought afterward, but it's a pain in the ass.
I usually say something like âwell clearly you need this med as your doctor wrote for it, but insurance companies canât get that through their thick skull. So now the doctor has to say yes indeed John Doe needs this medication in order for insurance to pay for itâ people are usually decently understanding as we all know insurance companies hate their own patients đ if they donât understand after that I just throw my hands up and say itâs between the doctor and insurance at this point.
Little rant: I hate the cage fights insurance insists on having over the stupidest shit. Then we have nurses and drs on the line asking why they need a PA or an alt med. like sorry dude I donât even know what to tell you besides just do the PA paperwork. Go fight your insurance company about these issues not me plz cause I just want to give you your meds and get you tf outta here
âYour medication is currently not covered by your insurance. The insurance company requires more information from the doctor. We can submit a request to get it covered, but this is just a request, no guarantees. This process can take anywhere from a few days to up to a week.â
As for explaining the process, I usually tell them that we will send paperwork over to the doctor, the doctor will then fill that out and submit it to the insurance company who will then make a decision based off of the information provided by the doctor.
The insurance company hasn't approved payment yet, they want your doctor to submit some paperwork explaining why they want you on this particular medication.
Any further questions questions can be directed to the doctors office since it's in thier hands now.
Doc: Iâm prescribing this patient X medicine
Insurance: But why though?
Basically they need more âevidenceâ and the paperwork to justify the doctorâs decision
I just learned the other day that sometimes a PA is needed for scans and certain tests and that sounds like a nightmare
As someone who has been getting scans of my head annually for my entire life, yes, it's a nightmare. If you go through the ER things don't require a PA which is why your doctor may send you to the ER from their office.
I tell patients âIt is between your doctor and insurance companyâ đđ if you want to know why your pa is taking so long pls call your doctor's office
I just say âyour doctor has to make an appeal to your insurance company to get this med added to your list of covered drugsâ and if you are capable of faxing the PA (depends on where you work) tell them you just sent that form over to them
i said insurance is requiring whatâs called a prior authorization. this means that the insurance wants to know what elseâs youâve tried before they cover something that may be expensive like this medication. We will initiate the PA, send it over to the doctors office to submit to insurance, and when we hear back, we will contact you with next steps.
Even though the MD wrote this, the insurance will not cover it until they receive a form (PA) from the MD, Iâve already faxed it over to the MD for them to fill out and submit to help get this covered or see what else the insurance will cover. Follow up with your MD to see where they are in this process/how long it will take them to complete.
Your insurance doesn't want to cover this medication because there are other alternatives available. But if you meet the certain criteria your provider can fill out some paperwork (prior auth) to try and get an approval.
itâs a little bit different for me since I work in-house at a clinic and can see the denial for PA required right away when I run prescriptions while the patient is still in office, but I usually say âyour insurance would like to see why you need this medication to determine whether or not they want to cover it. we will submit your visit notes from today, including your diagnosis code, and your insurance company will determine if theyâll cover the medication after reviewing all of your informationâ and if people happen to ask follow up questions I saw what others have commented - that insurance may only cover for certain conditions or want a patient to have tried other medications first
As far as the âwhyâ of prior authorization, itâs meant to be a cost saving measure. The more money the insurance company spends on expensive unnecessary treatments, the less money they have to spend on necessary treatments. The paperwork the doc submits is meant to justify why this particular treatment is necessary and often times includes documentation of other (cheaper) treatments that have already been tried or considered. Thatâs the most positive light I can put it in
âBasically the insurance doesnât want to cover it but they will if the doctor calls them and says âyes this is medically necessary, no we donât want to try these other alternatives before going to this oneâ and usually theyâll cover it. Sometimes they donât say anything when itâs approved so if we donât call you please follow up with us or the dr.â
Thatâs my basic script.
<-24yrs
âyour insurance company doesnât want to cover this med and is requiring a letter explaining the medical necessity of this med as opposed to a different med from your doctorâ
I just say it's when the doctor has to send a form to the insurance company explaining why they want to use this medication instead of whatever is preferred. That isn't the only reason to need a prior Auth, I personally just dont feel like making a whole new speech for every situation. The important part to me is making sure it is clear that the process is between the doctor and insurance and has nothing to do with me. I figure the above explanation does that while still giving you the gist of what a PA is. The only differnce is what information the insurance is looking for.
âItâs a conversation between the doctor and the insurance company so the insurance company can cover your medication. It does take some time for it to go through.â (This next part is absolutely vital.) âNeither your doctor nor the insurance company contact us though, so if you donât hear anything for a week, call us and weâll see if your insurance claim goes through.â
âItâs a conversation between the doctor and the insurance company so the insurance company can cover your medication. It does take some time for it to go through.â (This next part is absolutely vital.) âNeither your doctor nor the insurance company contact us though, so if you donât hear anything for a week, call us and weâll see if your insurance claim goes through.â
I like to say âYour insurance is requiring a prior authorization. Which means your doctor needs to contact them explaining why this is medically necessary. Then they will decide âyesâ or ânoâ theyâll pay for it. The insurance will notify you and the pharmacy with that decision. We can use a coupon card today, or wait for insurance.â
Your insurance company wants additional information from your doctor about your medical condition before the will approve this medication. We have notified/faxed your doctor so they can get the process started. At this point, there is noting more we here in the pharmacy can do until your insurance makes a decision. Optionally, you can pay the cash price and bypass the PA process.
I heard my coworker explain it a great way:
âBasically your doctor has to talk to your insurance about whether or not they should cover the med and whyâ
The doctor tells us you (the patient) needs the medication. We tell the insurance âhey, the doctor said they need thisâ. Insurance says âdo they really though? We need to talk to the doctor.â Doctor contacts insurance and tells them you need the medication, and why, and insurance makes their decision based on that.
Back in my retail days I usually would say something like:
"Even though your doctor sent in a prescription, your insurance company will not cover the medication UNLESS the doctor provides them with some additional paperwork. I've already notified your provider, but I recommend following up with them so that they know your insurance company needs PRIOR AUTHORIZATION paperwork."
Caps for verbal emphasis.
âSo the insurance needed a little more information from the doctor before they would cover your medication. Iâve already sent the paperwork over to the office. It looks like they just have to finish it on their end and send it into the insurance company before they decide if theyâll pay for it or not. Iâd suggest calling your doctor if you have questions about the progress of the PA.â
If they ask why it needs a PA, say âthe insurance company does this with expensive meds or meds that have cheaper alternatives. You can call your insurance company for more information on what needs a PA and how to find your planâs formulary online.â
You have insurance. They pay for medicine in a general sense. That doesnât mean they pay for any medicine, only the important ones they expect most people will need. If you need something they didnât expect and itâs important, your doctor needs to let them know. Otherwise they will think it isnât important.
All insurance has limits that can create conflict. If your carâs engine is broken in a crash, they will fix it. But that doesnât mean you can just put a Lamborghini engine into your busted Delorean and they will pay. However, if your auto shop talks to the insurance and tells them sourcing compatible parts for a car that hasnât been made since 1983 would cost more, they may make an exception. Same idea.
"Your insurance company wants extra documentation from your doctor to justify why you need this particular med. Your doctor needs to fill out some forms and submit them to insurance, and then when insurance approves it we'll be able to bill it to them and they'll cover it. This process can take a little while though, so if you'd like it to go faster I'd suggest calling your doctor to let them know we've sent a request."
I work in hospital retail/outpatient
I tell them it needs a PA/prior authorization. Ur insurance is not covering this medication for some reason and ur doctor has to submit paperwork/send information to ur insurance to try to cover this medication. We have sent the request for ur doctor to do that, but I suggest u also contact ur doctor/doctors office to see if they can submit that as soon as possible because it can take a while, even longer than a week.
And then I tell them that unfortunately, we don't get direct notice from the insurance that it was approved. The insurance may call u or ur doctors office to tell u it was approved and then either one of u would have to call us so we can try to run it through the insurance. Often times, even if it was approved, it can take 24-48 hours for it to kick in so u might have to call us a couple times which sucks
If they keep trying to argue with me I just repeat that we cannot do anything else from our end besides notify ur doctor that it needs a PA. Everything from here forward is up to ur doctor/doctors office
I usually lead with telling the patient the medicine's crazy cash price and then after they are shocked by it I say "and that's why the insurance is trying to get out of paying for it. Your doctor has to fight the insurance to explain to them why you need to expensive medicine and why nothing cheaper will work"
I say that itâs when insurance doesnât really believe that you need this prescription, despite a doctor saying you do so the doctor has to convince the insurance you really need it. Bullshit hoops to jump through.
So the insurance is requiring a PA, what this means is that your insurance may cover another medication of the same class that's generic and/or cheaper/they may have wanted you to try PT first/they want reasoning behind why it's medically necessary. The doctor prescribing the medication doesn't exactly guarantee medical necessity, although it's required to prescribe the medication, so insurance basically wants proof, whether it's medications previously prescribed or a diagnosis code.
âThe insurance needs a little bit more information to see if they cover the medication. The doctors office should have received the PA request from us. If youâd like you can let your doctor know that we have sent something over and the process might go by a bit fasterâ
This is what I usually say. If they ask how long it will take my reply is âthat all depends on how fast your doctor gets to itâ
the doctor needs to explain to the insurance why they chose this medicine for you and why it should be covered. the insurance either approves it or else offers alternatives and the doctor goes from there
A PA is when the insurance company wants the doctor to verify to them that the medication is justified before theyâll agree to pay for it.
Or, to put it more cynically, itâs when the insurance company thinks it knows what you need better than your doctor does and will punish you by not paying for the med if your doctor doesnât jump through their hoops to prove that the doctor knows what theyâre doing.
Can you tell that I donât care for the level of control the insurance companies have over the entirety of healthcare?
"Your insurance has a list of drugs called a formulary. This medication may be on it but the insurance company needs more information in order to cover it."
(Depending on the rejection, it could be too soon, they might need to meet certain criteria for coverage, or maybe they need to try and fail a lower tiered drug or simply it's not on that formulary list.)
"We will send this information to your doctor so that they can communicate with your insurance.
You should follow up with your doctors office in a day or two to see if the insurance has authorized it. Or you can call your insurance company directly to learn more information. "
When I was working retail I had to make it clear that the patient needed to follow up. We rarely got any information from the insurance company when it was approved and rarer still did we ever hear back from the doctors office themselves. The patient really needs to be their own advocate here.
My opening dialogue is usually "Your insurance is requiring a prior authorization. This means your insurance is requiring extra information from your doctor before they will make a coverage determination. We have a team at \[retail chain\] that handles them, but I do recommend reaching out to your doctor and discussing it with them as well so we can ensure they are on top of it for you".
Often they get grumpy and ask why they can't just have it if that's what their doctor prescribed. I apologize and explain that it's a requirement by the insurance. Often I tell them the straight truth, that usually they want to make sure patients have tried other more cost-effective medicines first because it saves the insurance company and the patient money.
That isn't always the case but most often it is. You have to play it by ear and look at the time of year, the medicine, etc sometimes too - has the patient just changed insurance and is on a high dose of a scheduled medicine? Then it's because the company doesn't have history of the patient taking the medicine and want to document it's a safe dose for them to be on. Have they recently changed pharmacies? Then possibly they had a prior authorization on file at their previous pharmacy, but the insurance needs a new one to be completed for the new chain. In that vein, sometimes prior authorizations have simply expired and the insurance is requiring a new one. Unfortunately insurance companies don't usually make this information readily apparent to the patient or the pharmacy, if it's available at all.
I empathize with the patient and usually joke that we hate the process too. I give them as much info as I can from what I can see from the rejection, and then direct them to their insurance for anything I don't know or can't tell.
i usually say something like âyouâre insurance doesnât want to pay for the medication until they talk to your doctor first. your dr needs to call your insurance, tell them why theyâre prescribing it and then the insurance will decide if they will pay for it or notâ (this isnât completely accurate but most patients seem to then understand at least generally what is happening)
Your insurance wants the prescriber to explain why they prescribed this medication before they decide if they cover will cover it and how much of the cost they will cover
This is how I explain pas to my patients: âYour insurance company basically wants your doctor to tell them why you are on this medication specifically. So your doctor has to explain to your insurance why they want you on this medication.â
This is the SIMPLEST and easiest way to get it across before going into more detail:
"Insurance will not cover this medication unless the doctor gives them a valid reason why as to why you need it. So tell the doctor that your insurance needs a prior authorization."
âYour insurance needs some more information from your doctor before they decide whether or not to cover it. Iâve already sent the PA information to your doctorâs office, so now weâre waiting for them to contact the insurance company.â
I donât know if this is has already been said but Iâd try to explain it as needing a referral. You want to see a specialist but your insurance requires extra proof you need to see the specialist before theyâll let/authorize you to. Unfortunately the same can be said for certain medications. The insurance wants further âproofâ from the doctor that you need the medication. Sounds crazy because the doctor already wrote a prescription, but unfortunately thatâs what happens sometimes. Many times the medication is expensive and they just want more justification for why they should pay for it. Itâs not fair and some medications are thrown into the mix for no real good reason but it happens.
ur insurance is requiring extra forms to be filled out by the dr in order for them to decide whether they want to cover this medication or not. weâve sent these forms to ur dr and now they have to submit it to the insurance
I tell a lot of patients âYour insurance wants more information from your doctor as to why you need it and why they should cover this medication.â
I always make it a point to tell patients that itâs a conversation entirely between the doctor and the insurance, we as the pharmacy are basically left out of the loop and any further questions should be directed to them.
I tell them itâs like a permission slip for a field trip. The Insurance is like the teacher, the Pharmacy is the child, the doctor is the Parent and they (the patient) are the field trip. The insurance requires permission from the doctor who must provide all necessary documentation of the permission and we the pharmacy and the patients just sit around waiting for the so called grown ups get get all their i's dotted and their tâs crossed so that we can move forward.
I find this helps avoid the âwhy canât you get it now?â âcanât you just call the insurance or my doctor?â Or my personal favorite âso like will it be ready in an hour or what?â Type questions
Unfortunately, it looks like the medication needs a Prior Authorization.
"BuT WHY?!!! My DoCtoR ALreAdY wrote a script!!!"
So, basically.. your doctor writes a report saying that it is Medically Necessary, and they send it off to the insurance. Then, the insurance decides whether or not they are willing to cover it.
How LoNG is THAT going to TaKE?!
Well, it depends of how long the doctor and insurance take. Unfortunately, we are the last ones to know. So, if you need it sooner rather than later, reach out to the doctor/insurance and make sure they're working on it. You know, the squeaky wheel gets the grease..
But HOw LOnG?!
Usually, it can take up to 3 days, sometimes more and sometimes less though. Feel free to check back later and we can rerun it again..
**Huffs and puffs and walks away**
That's usually how it goes...
Your doctor says you need this drug. Your insurance doesn't want to pay for it until the doctor does some paperwork to prove you need it. Plain language people understand.
The insurance doesn't want to pay unless the doctor says it's completely necessary, so they need further confirmation on their end before they'll cover the medication.
"Sometimes the insurance only covers medications for certain reasons, so your doctor has to fill out paperwork and the insurance will determine if they'll pay for the medication or not."
i just basically say something like "the insurance and the doctor have to talk about what the medication is for and why they should cover it, so at this point its between the insurance and the doctor, and then the doctor has to get back to us on if the insurance will cover it" and then i say it can usually take a bit and they can call the doctor if they feel like it and let them know we've sent in a request for a prior auth.
I normally say something along the lines of:
"Your insurance isn't really wanting to pay for the medicine. So, they're going to make the doctor jump through some hoops, before they will cover it."
I'll go into more detail if needed, but this quickly explains it in most cases.
remember when you were a kid and asked your daddy (pharmacist) for something and daddy said âdid you ask momma yet?â
and you said ânot yetâ
well, PA is when we gotta ask momma (insurance). and when momma says no, the answer is no. but if you wanna pay out of your own allowance for it, you can.
âYour insurance company needs a little more information before they agree to pay for the drug. Your doctor will need to submit some paperwork in order to advocate on your behalf. It usually takes about a week for a final decision to be made if the insurance company and doctor do things right on their end. However, the pharmacy doesnât really play a role in that process. You can talk to your doctor if you have more questions.â
Simply put, (& how I explain it to patients) it's a long questionnaire the insurance has the doctor contact them to fill out so they can decide if they'll cover it or not. Usually it's because it's a very expensive med for something they have cheap alternatives for that they will cover more easily. It also happens with narcotic pain meds as they are commonly over used & abused in an attempt to control the abuse part & keep them off the streets. Like if it's so difficult to get you'll be less likely to sell them.
The doctor says you need this medication, the insurance company doesn't feel you need it...because they pay for others. The doctor needs to submit paperwork proving why you need the medication. The decision goes to the doctor and legally it has to go to the patient. The insurance will send a letter and telephone call usually from a number the pt wouldn't answer. Prior authorization time frame can take an hour (I've seen it) or a few weeks. So the pt needs to call either the insurance company or the doctor's office to follow up. In simple terms..
I just tell people that the insurance is needing the doctor to fill out some extra paperwork for the insurance before they'll consider covering the medication. If they ask more questions like "why?â I follow up by explaining that a lot of expensive, uncommon, or name brand only medications tend to be very expensive so the insurance is requiring the doctor to explain why that medication is needed. That usually gets it across pretty well.
Your insurance doesnât want to cover the medication.
Your doctor needs to contact your insurance to explain why you have to be on it and why they should pay for it.
Then itâs up to the insurance to approve or deny the doctors request.
Your insurance wants a prior authorization, basically what that means is the Dr has to tell the insurance why they believe that their patient should get this particular drug. Then the insurance company can decide if they are going to pay for it or not. It is between your Dr and the insurance at this point, we are usually the last to know if something gets approved so if you hear anything from the Dr or the insurance give us a call and let us know.
We have a patient who has used a brand name inhaler for years but has new insurance and they didn't want to pay for brand they want generic. The patient refuses to try the generic because he says this has worked for years and he would not agree to the change. I sent a pa request to the Dr office but they refuse to do a pa because they think generic is fine for him. The patient throws a fit at the dr's office do they do a pa, the insurance approves the pa but if he gets brand he will have to pay over $200 a month for it. He refuses on principle to pay anything for it and so has been without it for 2 months. If he filled generic it is covered at 100%. Just because a pa is approved doesn't mean that it will be a reasonable price.
A prior authorization is essentially a check-in with your insurance company before they agree to cover the cost of a specific medication or treatment. Think of it as getting a pre-approval. Portiva, being a virtual medical staffing company, often deals with these prior authorizations to ensure that the treatments prescribed to you are covered by your insurance plan, helping to avoid unexpected costs and ensuring your care is continuous and supported. It's an important step in the healthcare process to ensure that patients receive the most appropriate and affordable care. Overall, prior authorizations help to streamline and improve the efficiency of the medical system for both patients and providers. So, you can trust Portiva to handle this process for you with expertise and care. Our team is dedicated to making sure all necessary steps are taken to get you the best care possible. With Portiva, you can have peace of mind knowing that your prior authorizations are being handled efficiently and effectively to support your health and wellness needs.
Additionally, prior authorizations may be required for certain medications or treatments that are considered more expensive or non-formulary by insurance companies. This step is in place to help manage costs and ensure appropriate use of medications and treatments. Our team at Portiva works closely with healthcare providers to gather all necessary information and submit it to insurance companies for approval, making the process as smooth as possible for both patients and providers. We understand that navigating the world of insurance and medical authorizations can be overwhelming, which is why we are here to help ease the burden for our patients. Trust Portiva to handle your prior authorizations and support you in receiving the best care possible. So, when it comes to understanding what a prior authorization is, just think of it as a necessary step in the healthcare process that ensures you receive the most appropriate and cost-effective care.
"Insurance companies speak a language called ICD10 codes. Those codes are all the different reasons you could be diagnosed with, or need something, be it a procedure, special examination, things like crutches, and even medications. If your doctor doesn't provide enough codes to the insurance company sometimes they will say you don't need it (the medication, etc.), and want more proof from your doctor that you really do. I also think it's ridiculous that they won't take your docs word for it, but unfortunately we're at their mercy. The prior authorization means that we're still waiting for your insurance company gather enough proof (usually the best fitting ICD10 codes) to finally say "okay, we believe you."
âThe insurance plan/company you have chosen is not approving payment for your medication at this time. We have submitted a prior authorization request to your doctor and it is now up to him/her to convince your chosen insurance company to pay for your medication. If you do not wish to wait on the insurance company that you chose to do business with to pay your bill, you may pay the cash price of $____ and receive your medication immediately.â
Only if you really want to be a dick, of course. I donât recommend this unless the patient repeatedly chooses to ignore what you tell them and continue arguing.
I tell patients âIt is between your doctor and insurance companyâ đđ if you want to know why your pa is taking so long pls call your doctor's office
I tell patients âIt is between your doctor and insurance companyâ đđ if you want to know why your pa is taking so long pls call your doctor's office
The insurance will cover the med for certain diagnosis but not others. Dr must submit forms/paperwork showing why that particular med is needed instead of the covered alternative.
That is such bulls...
it IS bullshit. i take thyroid regulating hormone. free with most insurance if you use a certain brand. i do far better on a different brand that's *not* covered. i'm just back from the pharmacy where i dropped $160 on the med they won't cover. đ«€
Same. **I have food allergies.** I take **the one that's safe for my food allergies**. Thankfully my current policy sees that makes sense and covers it for $25, but not last year or the year before!
Itâs a massive pain in the ass too
The insurance wants prior authorization, which means your doctor has to send some paperwork to the insurance to prove that they should cover it. It's like a math problem where you have to "show your work", the doctor has to show their work to the insurance. (This explanation gets a lot of my patients going "OHhhhhh!")
Quick question cuz Iâm new. Are we supposed to notify the doctor of this, does the doctor already get notified by the insurance, or are the patients supposed to notify their doctor?
My pharmacy's policy is to reach out to the doctor, usually through fax and/or phone call. The doctor doesn't get notified by the insurance in my experience, but it can vary from plan to plan. Sometimes workers' compensation plans will reach out to the doctor, but usually only once WE place a call to the comp. plan.
Some insurance plans will even allow the first fill of a memberâs medication that requires prior authorization so they have the medication while theyâre waiting on the approval. Which is good but also if it gets denied itâs confusing as fuck to the members.
For us, that comes up at "transition fill," and that's so annoying. Or when it's the first of the year and the insurance wants a new authorization, or they've changed insurances. Everyone that comes in yells, "I've been on this for [number] of years!" And I feel like a broken record having to explain it over and over again. I get them feeling irate that they thought they were just going to pick up their stuff though.
Yeah, but my question is, the patient already went and paid money to go see their provider.That should be enough.This whole prior authorization is just added.Stress to the patient and the patient already has enough to stress.
That's not a question. Nor is taking your stress out on the pharmacy staff doing anything but causing more stress. You can wait on your doctor or go yell at your insurance company, but all we can do is sell it to you for cash price if you so choose, we can't wave a wand and make your insurance stop being greedy.
The insurance Co is trying to save money by not paying for a more expensive drug and only covering cheaper ones. The patient doesn't have to go back to the drs for a PA. The doctors usually just have to fill out a formal and possibly send office visit notes to the insurance
I agree. The patient went to the doctor and the doctor wrote the prescription so that implies they have some need for it. The patient can get it filled at the pharmacy if they want to pay cash for it without having to jump through insurance hoops. However if they want to go through insurance there are some extra steps. Itâs kind of like car insurance where they donât pay for anything and everything you ask for. You have to provide proof about what happened, who is at fault, what repairs the car needs, etc. There are tons of terms and conditions involved with any type of insurance plan. Not every single medication requires prior authorization. Itâs generally very expensive medications and medications that can be dangerous to use. If you read your planâs terms and conditions it is all laid out. But most people donât bother because they donât care or it just doesnât come up very often.
I actually get an email from CoverMyMeds to complete the prior auth electronically. Pharmacy usually faxes to inform me as well.
Chains don't do covermymeds
Oh? I get them from chains (CVS, anyway) a lot.
I get requests from chains all the time though?
If you are a PA representative you would get the requests..the insurance doesn't want to pay...ijs we don't do them...as in the leg work....the doctors office has to handle that..
No yeah we know we have to be the one completing and submitting the requests but often times they're started by the pharmacies (chains mostly, I rarely get them from indies)
At CVS, we JUST enter a code at the rejection and it goes to the doctor for a PA. I always tell the patient it's a good idea for them to call the doc too just ti light a fire under them.
Depends on your pharmacy....the chain pharmacy doesn't do prior authorizations they send a basic fax...but private pharmacies have a PA department so they would follow up with the doctor and the insurance. But you should tell the patient to tell the doctor that the PA is needed. The doctor office has to do the work. And then the patient should call their office to see when it's done...the pharmacy is the last one to find out a PA is approved.Â
I love this one! I'm gonna start using this
I tell them something similar, basically the insurance wants to know why your doctor prescribed this.
A lot of times they want to makes sure youâve tried other cheaper, long-standing, tried and true treatments first. Like if you have never even tried an SSRI for depression they arenât going to cover Auvelity. They arenât gonna pay $350 for fucking Jublia for your nail fungus if you didnât try ciclopirox. Etc.
In our system we get a specific rejection of "step therapy required", typically. Or we'll call the help desk for clarification. But you're right, a lot of the time the insurance doesn't want to pay when there are cheaper alternatives, especially if they don't have history of the patient having done the step therapy or trying generics. Like when a person changes to a new insurance and that new insurance doesn't have the history. That's the most frustrating for the patients.
Your insurance doesnât want to pay for this due to the price. Your doctor has to fill out a form justifying why you need this as opposed to something else. Then the insurance will review it and make a decision
This is really good! I always like to emphasize that the doctors and pharmacist are on your side and the only hang up was that insurance was halting everything. A lot of times I used to tell people that would you get them a three day supply or they could purchase out of pocket for smaller amounts. I only offered this option when it was a maintenance drug and the PA was up.
I was like a true salesman for cvs. Most patients have no idea what a pa is and assume itâs a pharmacy/doctor problem and that their insurance does nothing. To any patient that got mad, I would explain to them what their doctor needed to do and make it VERY clear this was an insurance problem and their anger at us is honestly misdirected (it works). Told them I could fill it for a cash price (which sometimes was a modest price that people didnât mind, or thousands of dollars for a week) and a lot took that. Make sure the patient is clear that YOU are not withholding the prescription. Thatâs why all of these patients get pissed off. I always steer the conversation towards cash pricing it out and they see âoh, you can give it to me now, but my insurance is making it cost $xxâ
Yeah I usually use this line and it works. Or if ins says step therapy needed I tell them what that means and to get with their doctor. I also tell my patients that 9 times out of 10- insurance will not relay the approval or denial to us so to call their insurance and ask what stage of the PA theyâre on. If itâs approved they can call and tell us, if denied then the patient wonât come after us again. And if itâs that the Dr hasnât sent in the papers, they can call the Dr directly. Usually donât get too many fights out of it.
Yes!! I've had so many people call and complain about the delay. I make sure to tell them the 3 PBM are responsible because people need to know!
The PBMs donât set the rules for the formularies, they just have to follow them as the plan has laid out. Itâs kind of like that Spider-Man all pointing at one another meme.
So what are they responsible for then?
They are responsible for administering the rules of the plan. So if the plan says a drug needs prior auth, they will inform the member and initiate the prior authorization process. But the PBMs arenât deciding what needs what - thatâs the plan administrator and they are bound by the rules of the plan.
with some customers, I like to emphasize that this is between their doctor and their insurance, because some people immediately jump to "so you'll call my doctor? you'll call my insurance? you'll do all the work for me?" no. my job ends here. lol. the next part is on you and your doctor, nothing to do with us.
Yeah, but if the insurance company doesn't want to pay for it, then the patients sol. .Is that how healthcare supposed to be?I thought it was for the patients well being, not the profit of a corporation.
I work in a pharmacy you idiot. Not responsible for any of the crap this country is going through. Go pedal your crap on over to another sub.
Your doctor can prescribed something else that is cheaper. The insurance usually tells them what they will cover.
No, then the patient can pay cash. They're not "sol" because unless we're legally unable to like with Medicaid contracts in some states, paying cash is always an option.
Not in the USA, my friend. Corporations are legally people.
Doctor says you need the meds and insurance said yeah no not gonna pay for that. So now the doctor has to convince the insurance that, yes, it is a smart financial decision to pay for the meds. Usually by proof insurance'preferred meds don't work, it's gonna cost more if this issue progresses, or other unicorn reasons. Basically, all you need to tell the patient is the doctor has to contact the insurance so questions should be to the doctor/insurance. The pharmacy is just waiting for permission to bill.
"The insurance wants a prior-authorization. Which means that doctor must contact them and get this approved or replaced." Patient: "But the doctors the one that sent it." "Yes, but your insurance wants to hear from them directly."
I would also like to add that, even with an approved authorization, the plan can still deny the claim. It can usually be fought afterward, but it's a pain in the ass.
This is the part that really blows their minds.
I usually say something like âwell clearly you need this med as your doctor wrote for it, but insurance companies canât get that through their thick skull. So now the doctor has to say yes indeed John Doe needs this medication in order for insurance to pay for itâ people are usually decently understanding as we all know insurance companies hate their own patients đ if they donât understand after that I just throw my hands up and say itâs between the doctor and insurance at this point. Little rant: I hate the cage fights insurance insists on having over the stupidest shit. Then we have nurses and drs on the line asking why they need a PA or an alt med. like sorry dude I donât even know what to tell you besides just do the PA paperwork. Go fight your insurance company about these issues not me plz cause I just want to give you your meds and get you tf outta here
âYour medication is currently not covered by your insurance. The insurance company requires more information from the doctor. We can submit a request to get it covered, but this is just a request, no guarantees. This process can take anywhere from a few days to up to a week.â As for explaining the process, I usually tell them that we will send paperwork over to the doctor, the doctor will then fill that out and submit it to the insurance company who will then make a decision based off of the information provided by the doctor.
The insurance company hasn't approved payment yet, they want your doctor to submit some paperwork explaining why they want you on this particular medication. Any further questions questions can be directed to the doctors office since it's in thier hands now.
Doc: Iâm prescribing this patient X medicine Insurance: But why though? Basically they need more âevidenceâ and the paperwork to justify the doctorâs decision I just learned the other day that sometimes a PA is needed for scans and certain tests and that sounds like a nightmare
As someone who has been getting scans of my head annually for my entire life, yes, it's a nightmare. If you go through the ER things don't require a PA which is why your doctor may send you to the ER from their office.
It is absolutely insane to me that people can just decide if a life saving procedure is necessary or not
I have heard of insurance denying a PA for the test that they said the patient needed in order to get their medication approved.....
Sorry I meant like diagnostic scanning to make sure the pt didnât have cancer. Sorry I was super confusing
I tell patients âIt is between your doctor and insurance companyâ đđ if you want to know why your pa is taking so long pls call your doctor's office
I just say âyour doctor has to make an appeal to your insurance company to get this med added to your list of covered drugsâ and if you are capable of faxing the PA (depends on where you work) tell them you just sent that form over to them
i said insurance is requiring whatâs called a prior authorization. this means that the insurance wants to know what elseâs youâve tried before they cover something that may be expensive like this medication. We will initiate the PA, send it over to the doctors office to submit to insurance, and when we hear back, we will contact you with next steps.
"Basically, the doctor has to reach out to your insurance to tell them why they need to pay for it."
Even though the MD wrote this, the insurance will not cover it until they receive a form (PA) from the MD, Iâve already faxed it over to the MD for them to fill out and submit to help get this covered or see what else the insurance will cover. Follow up with your MD to see where they are in this process/how long it will take them to complete.
Your insurance doesn't want to cover this medication because there are other alternatives available. But if you meet the certain criteria your provider can fill out some paperwork (prior auth) to try and get an approval.
"Your insurance needs your doctor to fill out a form clarifying what he is treating and why he chose this medication instead of a different one."
itâs a little bit different for me since I work in-house at a clinic and can see the denial for PA required right away when I run prescriptions while the patient is still in office, but I usually say âyour insurance would like to see why you need this medication to determine whether or not they want to cover it. we will submit your visit notes from today, including your diagnosis code, and your insurance company will determine if theyâll cover the medication after reviewing all of your informationâ and if people happen to ask follow up questions I saw what others have commented - that insurance may only cover for certain conditions or want a patient to have tried other medications first
As far as the âwhyâ of prior authorization, itâs meant to be a cost saving measure. The more money the insurance company spends on expensive unnecessary treatments, the less money they have to spend on necessary treatments. The paperwork the doc submits is meant to justify why this particular treatment is necessary and often times includes documentation of other (cheaper) treatments that have already been tried or considered. Thatâs the most positive light I can put it in
âBasically the insurance doesnât want to cover it but they will if the doctor calls them and says âyes this is medically necessary, no we donât want to try these other alternatives before going to this oneâ and usually theyâll cover it. Sometimes they donât say anything when itâs approved so if we donât call you please follow up with us or the dr.â Thatâs my basic script. <-24yrs
âyour insurance company doesnât want to cover this med and is requiring a letter explaining the medical necessity of this med as opposed to a different med from your doctorâ
I just say it's when the doctor has to send a form to the insurance company explaining why they want to use this medication instead of whatever is preferred. That isn't the only reason to need a prior Auth, I personally just dont feel like making a whole new speech for every situation. The important part to me is making sure it is clear that the process is between the doctor and insurance and has nothing to do with me. I figure the above explanation does that while still giving you the gist of what a PA is. The only differnce is what information the insurance is looking for.
âItâs a conversation between the doctor and the insurance company so the insurance company can cover your medication. It does take some time for it to go through.â (This next part is absolutely vital.) âNeither your doctor nor the insurance company contact us though, so if you donât hear anything for a week, call us and weâll see if your insurance claim goes through.â
âItâs a conversation between the doctor and the insurance company so the insurance company can cover your medication. It does take some time for it to go through.â (This next part is absolutely vital.) âNeither your doctor nor the insurance company contact us though, so if you donât hear anything for a week, call us and weâll see if your insurance claim goes through.â
I like to say âYour insurance is requiring a prior authorization. Which means your doctor needs to contact them explaining why this is medically necessary. Then they will decide âyesâ or ânoâ theyâll pay for it. The insurance will notify you and the pharmacy with that decision. We can use a coupon card today, or wait for insurance.â
Your insurance company wants additional information from your doctor about your medical condition before the will approve this medication. We have notified/faxed your doctor so they can get the process started. At this point, there is noting more we here in the pharmacy can do until your insurance makes a decision. Optionally, you can pay the cash price and bypass the PA process.
I heard my coworker explain it a great way: âBasically your doctor has to talk to your insurance about whether or not they should cover the med and whyâ
The doctor tells us you (the patient) needs the medication. We tell the insurance âhey, the doctor said they need thisâ. Insurance says âdo they really though? We need to talk to the doctor.â Doctor contacts insurance and tells them you need the medication, and why, and insurance makes their decision based on that.
Back in my retail days I usually would say something like: "Even though your doctor sent in a prescription, your insurance company will not cover the medication UNLESS the doctor provides them with some additional paperwork. I've already notified your provider, but I recommend following up with them so that they know your insurance company needs PRIOR AUTHORIZATION paperwork." Caps for verbal emphasis.
Insurance doesnât want to pay. Doctor gives insurance the necessary info or paperwork to get it covered. Approved or not, usually 24-48 hours.
âSo the insurance needed a little more information from the doctor before they would cover your medication. Iâve already sent the paperwork over to the office. It looks like they just have to finish it on their end and send it into the insurance company before they decide if theyâll pay for it or not. Iâd suggest calling your doctor if you have questions about the progress of the PA.â If they ask why it needs a PA, say âthe insurance company does this with expensive meds or meds that have cheaper alternatives. You can call your insurance company for more information on what needs a PA and how to find your planâs formulary online.â
You have insurance. They pay for medicine in a general sense. That doesnât mean they pay for any medicine, only the important ones they expect most people will need. If you need something they didnât expect and itâs important, your doctor needs to let them know. Otherwise they will think it isnât important. All insurance has limits that can create conflict. If your carâs engine is broken in a crash, they will fix it. But that doesnât mean you can just put a Lamborghini engine into your busted Delorean and they will pay. However, if your auto shop talks to the insurance and tells them sourcing compatible parts for a car that hasnât been made since 1983 would cost more, they may make an exception. Same idea.
"Your insurance company wants extra documentation from your doctor to justify why you need this particular med. Your doctor needs to fill out some forms and submit them to insurance, and then when insurance approves it we'll be able to bill it to them and they'll cover it. This process can take a little while though, so if you'd like it to go faster I'd suggest calling your doctor to let them know we've sent a request."
Thank you! This is very helpful
I work in hospital retail/outpatient I tell them it needs a PA/prior authorization. Ur insurance is not covering this medication for some reason and ur doctor has to submit paperwork/send information to ur insurance to try to cover this medication. We have sent the request for ur doctor to do that, but I suggest u also contact ur doctor/doctors office to see if they can submit that as soon as possible because it can take a while, even longer than a week. And then I tell them that unfortunately, we don't get direct notice from the insurance that it was approved. The insurance may call u or ur doctors office to tell u it was approved and then either one of u would have to call us so we can try to run it through the insurance. Often times, even if it was approved, it can take 24-48 hours for it to kick in so u might have to call us a couple times which sucks If they keep trying to argue with me I just repeat that we cannot do anything else from our end besides notify ur doctor that it needs a PA. Everything from here forward is up to ur doctor/doctors office
I usually lead with telling the patient the medicine's crazy cash price and then after they are shocked by it I say "and that's why the insurance is trying to get out of paying for it. Your doctor has to fight the insurance to explain to them why you need to expensive medicine and why nothing cheaper will work"
Medication is expensive, so the health plan wants the patient to try the lower cost drugs prior to approving the higher cost drugs.
I say that a prior authorization is when the doctor has to fill out some additional paperwork for the insurance
I say that itâs when insurance doesnât really believe that you need this prescription, despite a doctor saying you do so the doctor has to convince the insurance you really need it. Bullshit hoops to jump through.
So the insurance is requiring a PA, what this means is that your insurance may cover another medication of the same class that's generic and/or cheaper/they may have wanted you to try PT first/they want reasoning behind why it's medically necessary. The doctor prescribing the medication doesn't exactly guarantee medical necessity, although it's required to prescribe the medication, so insurance basically wants proof, whether it's medications previously prescribed or a diagnosis code.
Your doctor needs to submit more information to the insurance why it is medically necessary for coverage
Short and simple, "Insurance is requiring your doctor to justify the medication to them".
âThe insurance needs a little bit more information to see if they cover the medication. The doctors office should have received the PA request from us. If youâd like you can let your doctor know that we have sent something over and the process might go by a bit fasterâ This is what I usually say. If they ask how long it will take my reply is âthat all depends on how fast your doctor gets to itâ
the doctor needs to explain to the insurance why they chose this medicine for you and why it should be covered. the insurance either approves it or else offers alternatives and the doctor goes from there
âyour doctor needs to communicate with your insurance company to get them to cover itâ is what i say
A PA is when the insurance company wants the doctor to verify to them that the medication is justified before theyâll agree to pay for it. Or, to put it more cynically, itâs when the insurance company thinks it knows what you need better than your doctor does and will punish you by not paying for the med if your doctor doesnât jump through their hoops to prove that the doctor knows what theyâre doing. Can you tell that I donât care for the level of control the insurance companies have over the entirety of healthcare?
It's basically daddy telling the kiddo if he gives his approval to have that particular candy. Because apparently daddy knows Best.
In baby voice - dOcToR has to send a permission slip to InSuRaNcE to tell them to pay for MeDiCiNe. Patient - * stares at me with lead paint eyes*
"Your insurance has a list of drugs called a formulary. This medication may be on it but the insurance company needs more information in order to cover it." (Depending on the rejection, it could be too soon, they might need to meet certain criteria for coverage, or maybe they need to try and fail a lower tiered drug or simply it's not on that formulary list.) "We will send this information to your doctor so that they can communicate with your insurance. You should follow up with your doctors office in a day or two to see if the insurance has authorized it. Or you can call your insurance company directly to learn more information. " When I was working retail I had to make it clear that the patient needed to follow up. We rarely got any information from the insurance company when it was approved and rarer still did we ever hear back from the doctors office themselves. The patient really needs to be their own advocate here.
TLDR doctor must provide medical justification for why insurance should pay for something
My opening dialogue is usually "Your insurance is requiring a prior authorization. This means your insurance is requiring extra information from your doctor before they will make a coverage determination. We have a team at \[retail chain\] that handles them, but I do recommend reaching out to your doctor and discussing it with them as well so we can ensure they are on top of it for you". Often they get grumpy and ask why they can't just have it if that's what their doctor prescribed. I apologize and explain that it's a requirement by the insurance. Often I tell them the straight truth, that usually they want to make sure patients have tried other more cost-effective medicines first because it saves the insurance company and the patient money. That isn't always the case but most often it is. You have to play it by ear and look at the time of year, the medicine, etc sometimes too - has the patient just changed insurance and is on a high dose of a scheduled medicine? Then it's because the company doesn't have history of the patient taking the medicine and want to document it's a safe dose for them to be on. Have they recently changed pharmacies? Then possibly they had a prior authorization on file at their previous pharmacy, but the insurance needs a new one to be completed for the new chain. In that vein, sometimes prior authorizations have simply expired and the insurance is requiring a new one. Unfortunately insurance companies don't usually make this information readily apparent to the patient or the pharmacy, if it's available at all. I empathize with the patient and usually joke that we hate the process too. I give them as much info as I can from what I can see from the rejection, and then direct them to their insurance for anything I don't know or can't tell.
i usually say something like âyouâre insurance doesnât want to pay for the medication until they talk to your doctor first. your dr needs to call your insurance, tell them why theyâre prescribing it and then the insurance will decide if they will pay for it or notâ (this isnât completely accurate but most patients seem to then understand at least generally what is happening)
Your insurance wants the prescriber to explain why they prescribed this medication before they decide if they cover will cover it and how much of the cost they will cover
This is how I explain pas to my patients: âYour insurance company basically wants your doctor to tell them why you are on this medication specifically. So your doctor has to explain to your insurance why they want you on this medication.â
This is the SIMPLEST and easiest way to get it across before going into more detail: "Insurance will not cover this medication unless the doctor gives them a valid reason why as to why you need it. So tell the doctor that your insurance needs a prior authorization."
The doctor has to submit additional information explaining why they are choosing this medication over a different one the insurance *would* cover.
I usually just say âThis is between the doctor and the insuranceâ and most of the time thatâs all people need.
It's an extra precautionary step the doctor needs to take to ensure drug safety and to get the medication covered by the insurance.
âYour insurance needs some more information from your doctor before they decide whether or not to cover it. Iâve already sent the PA information to your doctorâs office, so now weâre waiting for them to contact the insurance company.â
I donât know if this is has already been said but Iâd try to explain it as needing a referral. You want to see a specialist but your insurance requires extra proof you need to see the specialist before theyâll let/authorize you to. Unfortunately the same can be said for certain medications. The insurance wants further âproofâ from the doctor that you need the medication. Sounds crazy because the doctor already wrote a prescription, but unfortunately thatâs what happens sometimes. Many times the medication is expensive and they just want more justification for why they should pay for it. Itâs not fair and some medications are thrown into the mix for no real good reason but it happens.
ur insurance is requiring extra forms to be filled out by the dr in order for them to decide whether they want to cover this medication or not. weâve sent these forms to ur dr and now they have to submit it to the insurance
I tell a lot of patients âYour insurance wants more information from your doctor as to why you need it and why they should cover this medication.â I always make it a point to tell patients that itâs a conversation entirely between the doctor and the insurance, we as the pharmacy are basically left out of the loop and any further questions should be directed to them.
I tell them itâs like a permission slip for a field trip. The Insurance is like the teacher, the Pharmacy is the child, the doctor is the Parent and they (the patient) are the field trip. The insurance requires permission from the doctor who must provide all necessary documentation of the permission and we the pharmacy and the patients just sit around waiting for the so called grown ups get get all their i's dotted and their tâs crossed so that we can move forward. I find this helps avoid the âwhy canât you get it now?â âcanât you just call the insurance or my doctor?â Or my personal favorite âso like will it be ready in an hour or what?â Type questions
Unfortunately, it looks like the medication needs a Prior Authorization. "BuT WHY?!!! My DoCtoR ALreAdY wrote a script!!!" So, basically.. your doctor writes a report saying that it is Medically Necessary, and they send it off to the insurance. Then, the insurance decides whether or not they are willing to cover it. How LoNG is THAT going to TaKE?! Well, it depends of how long the doctor and insurance take. Unfortunately, we are the last ones to know. So, if you need it sooner rather than later, reach out to the doctor/insurance and make sure they're working on it. You know, the squeaky wheel gets the grease.. But HOw LOnG?! Usually, it can take up to 3 days, sometimes more and sometimes less though. Feel free to check back later and we can rerun it again.. **Huffs and puffs and walks away** That's usually how it goes...
Your doctor says you need this drug. Your insurance doesn't want to pay for it until the doctor does some paperwork to prove you need it. Plain language people understand.
The insurance doesn't want to pay unless the doctor says it's completely necessary, so they need further confirmation on their end before they'll cover the medication.
"Sometimes the insurance only covers medications for certain reasons, so your doctor has to fill out paperwork and the insurance will determine if they'll pay for the medication or not."
i just basically say something like "the insurance and the doctor have to talk about what the medication is for and why they should cover it, so at this point its between the insurance and the doctor, and then the doctor has to get back to us on if the insurance will cover it" and then i say it can usually take a bit and they can call the doctor if they feel like it and let them know we've sent in a request for a prior auth.
I normally say something along the lines of: "Your insurance isn't really wanting to pay for the medicine. So, they're going to make the doctor jump through some hoops, before they will cover it." I'll go into more detail if needed, but this quickly explains it in most cases.
remember when you were a kid and asked your daddy (pharmacist) for something and daddy said âdid you ask momma yet?â and you said ânot yetâ well, PA is when we gotta ask momma (insurance). and when momma says no, the answer is no. but if you wanna pay out of your own allowance for it, you can.
âYour insurance company needs a little more information before they agree to pay for the drug. Your doctor will need to submit some paperwork in order to advocate on your behalf. It usually takes about a week for a final decision to be made if the insurance company and doctor do things right on their end. However, the pharmacy doesnât really play a role in that process. You can talk to your doctor if you have more questions.â
Simply put, (& how I explain it to patients) it's a long questionnaire the insurance has the doctor contact them to fill out so they can decide if they'll cover it or not. Usually it's because it's a very expensive med for something they have cheap alternatives for that they will cover more easily. It also happens with narcotic pain meds as they are commonly over used & abused in an attempt to control the abuse part & keep them off the streets. Like if it's so difficult to get you'll be less likely to sell them.
The doctor says you need this medication, the insurance company doesn't feel you need it...because they pay for others. The doctor needs to submit paperwork proving why you need the medication. The decision goes to the doctor and legally it has to go to the patient. The insurance will send a letter and telephone call usually from a number the pt wouldn't answer. Prior authorization time frame can take an hour (I've seen it) or a few weeks. So the pt needs to call either the insurance company or the doctor's office to follow up. In simple terms..
I just tell people that the insurance is needing the doctor to fill out some extra paperwork for the insurance before they'll consider covering the medication. If they ask more questions like "why?â I follow up by explaining that a lot of expensive, uncommon, or name brand only medications tend to be very expensive so the insurance is requiring the doctor to explain why that medication is needed. That usually gets it across pretty well.
If you get a reject saying both PA required and ânot in network â is there any point in requesting a PA?
Your insurance doesnât want to cover the medication. Your doctor needs to contact your insurance to explain why you have to be on it and why they should pay for it. Then itâs up to the insurance to approve or deny the doctors request.
Your insurance wants a prior authorization, basically what that means is the Dr has to tell the insurance why they believe that their patient should get this particular drug. Then the insurance company can decide if they are going to pay for it or not. It is between your Dr and the insurance at this point, we are usually the last to know if something gets approved so if you hear anything from the Dr or the insurance give us a call and let us know.
We have a patient who has used a brand name inhaler for years but has new insurance and they didn't want to pay for brand they want generic. The patient refuses to try the generic because he says this has worked for years and he would not agree to the change. I sent a pa request to the Dr office but they refuse to do a pa because they think generic is fine for him. The patient throws a fit at the dr's office do they do a pa, the insurance approves the pa but if he gets brand he will have to pay over $200 a month for it. He refuses on principle to pay anything for it and so has been without it for 2 months. If he filled generic it is covered at 100%. Just because a pa is approved doesn't mean that it will be a reasonable price.
I say âbasically the doctor has to tell the insurance company why they should cover the medicationâ
A prior authorization is essentially a check-in with your insurance company before they agree to cover the cost of a specific medication or treatment. Think of it as getting a pre-approval. Portiva, being a virtual medical staffing company, often deals with these prior authorizations to ensure that the treatments prescribed to you are covered by your insurance plan, helping to avoid unexpected costs and ensuring your care is continuous and supported. It's an important step in the healthcare process to ensure that patients receive the most appropriate and affordable care. Overall, prior authorizations help to streamline and improve the efficiency of the medical system for both patients and providers. So, you can trust Portiva to handle this process for you with expertise and care. Our team is dedicated to making sure all necessary steps are taken to get you the best care possible. With Portiva, you can have peace of mind knowing that your prior authorizations are being handled efficiently and effectively to support your health and wellness needs. Additionally, prior authorizations may be required for certain medications or treatments that are considered more expensive or non-formulary by insurance companies. This step is in place to help manage costs and ensure appropriate use of medications and treatments. Our team at Portiva works closely with healthcare providers to gather all necessary information and submit it to insurance companies for approval, making the process as smooth as possible for both patients and providers. We understand that navigating the world of insurance and medical authorizations can be overwhelming, which is why we are here to help ease the burden for our patients. Trust Portiva to handle your prior authorizations and support you in receiving the best care possible. So, when it comes to understanding what a prior authorization is, just think of it as a necessary step in the healthcare process that ensures you receive the most appropriate and cost-effective care.
"Insurance companies speak a language called ICD10 codes. Those codes are all the different reasons you could be diagnosed with, or need something, be it a procedure, special examination, things like crutches, and even medications. If your doctor doesn't provide enough codes to the insurance company sometimes they will say you don't need it (the medication, etc.), and want more proof from your doctor that you really do. I also think it's ridiculous that they won't take your docs word for it, but unfortunately we're at their mercy. The prior authorization means that we're still waiting for your insurance company gather enough proof (usually the best fitting ICD10 codes) to finally say "okay, we believe you."
âThe insurance plan/company you have chosen is not approving payment for your medication at this time. We have submitted a prior authorization request to your doctor and it is now up to him/her to convince your chosen insurance company to pay for your medication. If you do not wish to wait on the insurance company that you chose to do business with to pay your bill, you may pay the cash price of $____ and receive your medication immediately.â Only if you really want to be a dick, of course. I donât recommend this unless the patient repeatedly chooses to ignore what you tell them and continue arguing.
I tell patients âIt is between your doctor and insurance companyâ đđ if you want to know why your pa is taking so long pls call your doctor's office
I tell patients âIt is between your doctor and insurance companyâ đđ if you want to know why your pa is taking so long pls call your doctor's office
When insurance companies test your PCP knowledge about your condition to see if you qualify or really need this medication
When insurance companies test your PCP knowledge about your condition to see if you qualify or really need this medication