Health care companies use a prior authorization form to determine if the company covers a prescribed medication or procedure. A heath insurance company may not cover a medication or procedure without prior authorization, so without one, the patient may have to pay more out of pocket.
The prescribing physician's staff members are responsible for contacting the patient's health insurance company to determine if they need prior authorization. The staff members fax a prior authorization form to the insurer. The physician may file an appeal if the insurer denies the medication or procedure. The prior approval procedure may take up to 30 days to complete, and each insurer has a different process.
Reasons that health insurance companies require prior authorization on some medications and procedures include the patient's age, medical necessity and the availability of alternative generic medications. Some health insurance companies use prior authorization on medications that are harmful if combined with other medications, those that may be abused, and those that have dangerous side effects. Prior authorization saves consumers money by preventing unnecessary procedures and preventing physicians from prescribing expensive brand-name medications when equivalent generic medications are available. If the health insurance company denies authorization, the patient may not receive the medication or procedure or may have to go through step therapy.