A lady called physician’s office with whom I am working. She was distressed because all of a sudden she was unable to get one of her medicines because she needed our office to submit a prior approval application.

She was frustrated, upset and worried about what she was going to do since she was almost out of medication. She was also feeling singled out and picked on by the insurance company.

With that experience fresh in my mind, here are 10 things to know about the medication prior approval process.

  1. You certainly are not alone. Increasingly, insurance companies and pharmacy benefit managers are implementing prior approval requirements for certain medications (mostly brand names where generic alternatives are available).
  2. Every insurance plan has their own custom prior approval requirements. Many think that their insurance plan is the name of the company that insurance plus the product (example: Blue Cross Blue Shield PPO, Aetna HMO, Blue Cross Blue Shield POS). Actually, your plan is customized for your group. So there may literally be thousands of different plans underneath the umbrella of the type of insurance you have. Subsequently, it is next to impossible for your prescriber to know which medications need prior approval and what the approval criteria is for specific medications.
  3. Brand name medications that are used to treat attention deficit disorder, insomnia, asthma, allergies, erectile dysfunction, irritable bowel syndrome, rheumatoid arthritis, osteoporosis, osteoarthritis and elevated cholesterol levels often require prior approval.
  4. To get drugs approved, most pharmacy benefit companies have forms that must be completed by the doctor. Some companies do have phone numbers to call, but here again, this needs to be done by someone in your doctor’s office.
  5. Medication prior approvals usually expire after a year.
  6. Some medication prior approvals are for specific doses of medications. If the dosage changes, you may be required to seek another prior approval.
  7. Because of the increasing numbers of medicines being added to prior approval lists, medical offices are very busy responding to requests for prior approval. Please give your provider’s office at least a week to complete the process.
  8. Once the medical office completes the process, sometimes it takes up to three days for the approval to get into the system so that the pharmacy can fill the prescription.
  9. Information that is needed for medication prior approvals can include: your name, your insurance subscriber number, your birthday, your diagnosis, and prior medications used to treat your condition, dates of treatment and reasons they were discontinued.
  10. Patients/consumers can really be of assistance by keeping up with the expiration dates of medication prior approvals. Many prescribers are happy to help a patient that is trying to make this process easier.