Prescription Pre-authorization
Pre-Authorization of Prescriptions
Many insurance plans have a drug benefit plan which is managed by a third party such as Anthem Rx, Medcohealth or AdvanceRx. Some plans have a tiered system of copayments with some drugs having a low copayment, others a medium copayment and others a high copayment. Many plans require pre-authorization before they will fill a drug at all. You should check with your insurance plan to see what rules you will need to follow. You should also be able to get a listing of drugs which require pre-authorization and those in each tier of copayment. We try to provide you with effective and cost effective prescriptions, but we cannot always keep up with the numerous rules and changes for all the insurance plans with which we participate.
Your insurance plan may require you to try alternative medications prior to more expensive medications. They often require written documentation that you have had an "adequate" trial of the alternative medication. Some medications may not be covered at all depending on your drug plan coverage.
If you are told by the pharmacist that you need pre-authorization please contact your drug benefit plan to get the forms you will need. You should be able to get most of the forms from the plan's website. It is not as simple as "just have your doctor call for pre-authorization". Each plan has different forms and different rules. Once you get the form, see if you meet all the criteria for coverage. If you do, send us the form and we can start the process. If you do not meet the criteria set out by your insurance plan they will not cover the medication, or will require a higher copayment.
We realize that this is a significant inconvenience for you. Hopefully this information will make the process a little easier.