Why Do You Need Prior Authorization for Prescription Drugs?


Quick Answer

Prior authorization is necessary when a medical insurance provider requires a review of the requested medication before the patient's insurance plan covers it, says Blue Cross Blue Shield. Reasons for this include that the drug has dangerous side effects, it's harmful when combined with other drugs, it is only for use for certain health conditions, people commonly misuse or abuse it, or a less expensive drug may work better.

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Full Answer

If a prescription medication needs prior approval, the pharmacist informs the patient, and she must contact the doctor or wait for the pharmacist to contact the doctor. The doctor may choose to prescribe a drug that doesn't require prior approval instead, or he may contact the insurance company and provide the information it needs to begin the approval process, says Blue Cross Blue Shield. If it is a case that needs immediate attention, insurance companies may provide a way to expedite the process, provided there is a good reason. In some cases, the insurance company can pre-approve the drug. The patient should discuss these options with her doctor.

A patient can choose to ignore prior authorization requirements, but this may mean that the medication costs more, or the insurance company may not be cover it at all, according to Blue Cross Blue Shield.

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