Medicine Prior Authorization

Certain medicines or services may need to be approved by your insurance plan before they are covered. The approval process is called a prior authorization (PA). PAs may be needed for:

• Medicines that are very expensive and have lower cost options
• Medicines that should only be used for patients with a specific medical condition
• Medicines that can be dangerous

What to Do

You do not have to submit anything for the PA. You may need to get labs drawn or other tests done. Call the clinic if you have any changes in your insurance. If you want to check the status of your PA, contact the doctor’s office.

Getting Approved

PAs are typically handled by the doctor’s office. The office staff will talk to your insurance company and explain why they want you to use this medicine. Usually, the insurance company wants to know which medicines you have already tried. The insurance company will review the information and make a decision to approve or deny the PA. Sometimes, the insurance company will ask for more information from your doctor before they can make a decision. Once approved, the pharmacy will be able to bill your insurance for the medicine that you need. This process can take around 10 business days, depending on the medicine and insurance plan.

Getting Denied

If your insurance company does not approve (denies) a PA, your doctor can submit an appeal or change your medicine to another option that is covered by your plan. The appeal process lets the insurance company review your PA a second time. Usually, the doctor will include extra information to help get the PA approved. This process can take about 30 days.

Medicine Prior Authorization (PDF)

HH-V-280 11/19 | Copyright 2019, Nationwide Children’s Hospital