Why prior authorization, or approval, may be needed

female doctor speaking with older woman

You just came back from a doctor’s appointment and were given a new medicine for your condition. You go straight to the pharmacy and the pharmacist tells you that you need to get prior authorization for this new treatment. Um … what’s prior authorization?

If this concept is foreign to you, you’re not alone. Many have not heard this term until they’re faced with getting prior authorization from their insurance company before they can fill a prescription or start a medical procedure. Once you understand what it is and why it’s needed, you’ll see that prior authorization is there to help you manage costs and that the healthcare system is working for you.

What is prior authorization?

Prior authorization is essentially getting approval from your insurance company for a procedure or a prescription your doctor prescribes. It’s an important step to make sure you’re getting the procedure you need and aren’t prescribed costly medicines when there are alternatives you can try.

When is prior authorization needed?

Prior authorization may be needed for multiple reasons. A few examples include:

  • There may be a generic version or lower-cost alternative to the medicine you’re prescribed that you can try first.
  • The medicine can be dangerous to take with another medicine you’re taking.
  • The medicine is a controlled substance and more likely to be abused or misused.
  • 2 different doctors may be ordering the same tests, which may not be necessary.1

It’s important to note that you must obtain prior authorization first before filling your prescription or starting your treatment. If you don’t, you may be expected to pay the entire medical bill out of pocket without help from your insurance. That’s why it’s essential to work with your insurance company to make sure you have necessary approvals in place before you start your treatment.

Trust the process

The purpose of prior authorization is to make sure you have the right treatment for your condition and that it’s medically necessary. At Humana Pharmacy®, we reach out to your doctor directly if you need prior authorization before we fill the prescription, so you don’t need to worry. If we’re unable to reach your doctor, we’ll let you know there may be a delay in your order. We may also ask you to contact your doctor in order to expedite the process and ensure you have your medicine on time.

Find out more

If you have Humana insurance, you can find more information about prior authorization and steps you need to take.

To see which drugs require prior authorization, search Humana’s Drug List:

Medicare Drug List

Employer-based Drug List

Source:

1. Michael Bihari, “Prior Authorization: Insurance Companies Use Prior Authorization to Keep Health Care Costs in Check,” Verywell Health, last accessed June 13, 2019, https://www.verywellhealth.com/prior-authorization-1738770