If you’ve ever been informed at the pharmacy that your common medications that require Prior authorization, you know how confusing and infuriating it can be. All of a sudden the prescription your doctor gave you can’t be filled until the insurance company says it can.
This extra step in the prior approval system always delays patient care, creates an additional level of paperwork for medical professionals and adds undue frustration for patients. But here’s the upside: knowing which drugs can require prior authorization ahead of time will likely save you a lot of hassle, money and heartache.
What Is a Prior Authorization?
Common medications that require prior authorization.A prior authorization (PA or prior auth) is when your health insurance company limits their coverage of a prescription drug or your doctor’s recommended medical or surgical service through other restrictions.
You can think of it like a checkpoint in the health care system. Your insurance company wants to ensure the care you receive is medically necessary, cost-efficient and complies with preauthorization criteria. According to Dr Resneck, a former president of the American Medical Association (AMA), prior authorisation is a frequent barrier that delays care.
Prior Authorization for Medical Treatments
It’s more than prescription drugs that require approval. Other types of medical services, including physical therapy, certain lab tests and even some medical equipment can also be subject to prior authorization requests. This is a tool that insurance companies utilise in managing payments and determining medical necessity.
For instance, a patient who needs physical therapy after surgery may encounter a prior authorization request in order to show that the therapy is necessary before the health plan will pay. This process takes time and may be anxiety-producing for patients and work inducing on behalf of medical providers.
Types of Prescriptions that Require Prior Authorizations?
- What types of drugs are generally subject to approval? Here’s a comprehensive guide:
- Brand-name drugs: Insurance companies often prefer that patients begin with cheaper generic medications.
- High-cost drugs – Specialty prescription drugs for rare conditions or severe illnesses are likely to be put on the REQUIRED PRIOR AUTHORIZATION LIST.
- High-risk drugs – Some painkillers or drugs used to treat bipolar disorder and manic depression can be listed as requiring safety warnings.
- Drugs for Special Stores of the Population – Its coverage is limited to certain medical histories that prove you will meet the required conditions.
Drugs That May Require Prior Authorization
Here are a few examples of prescription drugs with relatively common prior authorizations:
- Asthma and DCOP medications, including Advair and Symbicort.
- Diabetes drugs, like Ozempic, Trulicity and Jardiance.
- Drugs for the treatment of mental health, such as Latuda for bipolar disorder and Seroquel XR for manic depression.
- Cholesterol medications such as Zetia, and PCSK9 inhibitors (Repatha).
Specialty medications for rare diseases (such as Cerezyme) or fertility treatments (such as Follistim AQ).
List of Drugs Needing PA
A partial simplified REQUIRED PRIOR AUTHORIZATION LIST is below. Note: Lists of covered services vary by health plan, so always check with your insurance company for the latest information.
| Drug Class | Examples of Drugs Needing PA | Preferred Alternatives |
| Asthma / COPD | Alvesco, Asmanex, Spiriva | Flovent, Pulmicort, QVAR |
| Diabetes (Injectables & Oral) | Ozempic, Trulicity, Bydureon, Jardiance, Steglatro | Metformin, Janumet, Synjardy |
| Mental Health (Bipolar/Depression) | Latuda, Seroquel XR | Generic quetiapine, lithium |
| Anticoagulants | Pradaxa, Savaysa | Warfarin, Eliquis, Xarelto |
| Gastrointestinal (IBS/Constipation) | Amitiza, Motegrity, Trulance | Linzess, lubiprostone |
| Osteoarthritis (Viscosupplements) | Synvisc, Monovisc, Orthovisc | Euflexxa, Supartz FX |
Prior Authorization (PA) Is Required for Certain Drugs
The prior authorization rules differ from one health insurance company to another but typically there are certain causes such as :
- To determine whether a generic medication could be substituted.
- To confirm the medication aligns with the treatment regimen for that condition.
- To verify that patient care will not be jeopardized if lower-cost options are tried first.
If, for instance, a patient wants an expensive new diabetes drug the insurance company wants evidence that other older and cheaper medications like metformin did not work to control blood sugar.
Step-by-Step Guide: How the Prior Authorization Process Works
When your pharmacist tells you that he or she needs approval for a drug, here’s what happens in 32 simple (OK, not so simple) steps.
- Pharmacy tells the provider – The pharmacist calls your doctor or provider.
- Provider makes request — Your healthcare provider submits forms that say you need the treatment and have a relevant medical history.
- Insurance company review – The health insurance company reviews the prior authorization request.
It can be a time-consuming process, often requiring several days or weeks even, and this delay can slow treatment which both patients and providers find frustrating.
REQUIRED PRIOR AUTHORIZATION LIST
Every insurance company or health plan has its OWN REQUIRED PRIOR AUTHORIZATION LIST. This is in fact a list of the drugs on which they require PA such as:
- Specialty treatments
- High-cost medications
- Certain brand-name drugs
- Drugs for chronic conditions
Groups like National CooperativeRx and large health insurance companies frequently update these lists, so it’s always a good idea to check before beginning a new treatment.
What Happens if Prior Authorization Is Denied?
If your request for prior authorization is rejected, all isn’t lost. You can:
- File for an appeal -Your medical provider can submit new information, proving to be more medically needful.
- Ask about alternatives — Sometimes another specific medication will work just as well.
- Utilize patient assistance programs – Patients are often able to obtain help from drug manufacturers and pharmacy benefit plans for discounted medications.
This means patients can still get the treatment they need and leave while laundering is in progress.
Final Thoughts:
Knowing which are the most popular drugs requiring prior authorization is key to not having to deal with maddening holdups in receiving treatment as a patient. Though sometimes it seems like there is a certain inertia of the prior authorization process, it’s about getting everyone on the same page and maintaining a fine balance — between medical necessity, costs and patient safety.
Understanding how insurance companies operate, looking at the REQUIRED PRIOR AUTHORIZATION LIST – before you have any tests done or fill your scripts with them, and keeping in close contact with your medical professionals can help you be a more informed healthcare consumer.
Do you require help taking care of your medications or dealing with the prior authorization process? Reach out to us – We would love to identify a treatment provider who will work well for you. Do not let delays stand in the way of receiving the care you need.
FAQs:
1. Which medications usually need prior authorization?
Specialty drugs, expensive brand medications, cancer treatments, mental health drugs, and opioids often require PA.
2. Do all insurers require the same drugs to go through PA?
No. The list of drugs needing PA is different for each insurance company.
3. How long does approval take?
It can be a few hours or several days, depending on the medication and insurer.
4. Can a PA request be denied?
Yes. If denied, patients can appeal by providing additional medical records or consult with the doctor about alternative options.
5. Why is prior authorization important?
It ensures safety, prevents unnecessary costs, and confirms that the drug is being used correctly.
