What’s The Holdup? Prior Authorizations Explained

Blue Cross card

Have you ever tried to fill a prescription at a pharmacy only to be told that it requires a prior authorization? Then you wait, seemingly forever, until you finally are told the prescription is ready to be picked up. But what is a prior authorization and what causes that long delay? Is there a method to the pharmacy staff’s madness?

A prior authorization is a term used by insurance companies for a prescription that requires further investigation. The company may be questioning the appropriateness of the medication, the directions, or even the therapy. A prior authorization may also be used as an automatic system check for extremely expensive drugs.

Once the prescription is flagged in the system, the prescriber must provide specific information to the insurance company demonstrating why he or she has prescribed this medication with these particular instructions. Until that time, the claim is stuck in limbo and you can either pay out of pocket or wait until the prior authorization is approved. Many times if your prescriber is following current clinical guidelines and has sufficient evidence why it’s medically necessary for you to be on the drug, then the insurance company will pay for the claim. However, if the prescriber isn’t able to successfully argue his or her case, then the claim will be rejected and the healthcare provider will prescribe an alternative medication or therapy.

But why the long wait? Prior authorizations are bureaucracy at its finest. The prescriber (or his or her agent) must provide specific information and if one little thing isn’t filled out or is incorrect, then it’s rejected. Submitting and receiving an approved or denied claim usually takes several business days, and most prescribers’ offices have only one or two dedicated staff who deal with prior authorizations for the whole office. So the approval of a prior authorization can take anywhere from a few days to even a month.

Most pharmacies will contact the prescriber as a courtesy as soon as they receive the prior authorization rejection from your insurance. Depending on the individual staff and the pharmacy’s protocols, they may continue to follow up with the prescriber and insurance company on your behalf. But don’t rely on the pharmacy staff alone for a resolution. Oftentimes the pharmacy staff is unable to reach someone at your prescriber’s office directly, which can increase the time it takes for an approved claim. In these situations, if you personally follow up with your prescriber’s staff, the prior authorization usually can be resolved much sooner.

About the Author

Julie Kaplan, Pharm. D.
Julie Kaplan is a licensed pharmacist in Virginia and the District of Columbia. She received a Bachelor’s of Arts in English from The College of William and Mary and a Doctor of Pharmacy from Virginia Commonwealth University. She has experience in patient communication from working as a retail pharmacist.