Prior Authorizations

Prior Authorizations are an attempt by insurance companies to avoid paying for medications that your physician has deemed necessary for your care. Our physicians and staff have no way of knowing which medications may require a prior authorization (PA). Please note that the list of medications that require a PA may change every year. It is not uncommon for a medication you have used for years to suddenly be off the insurance companies preferred list of medications (Formulary).

If you are informed by the pharmacy or our staff that your medication is no longer covered and/or needs a Prior Authorization, you have three options:

  1. Call your insurance company (number on the back of your card) or check their website and ask them specifically for medications covered WITHOUT a prior authorization (also known as a Formulary). If this is for an inhaler, check the chart below to guide you on equivalent agents which are grouped in rows or under the same colored banner. Call our office and provide us a list of these covered medications and a physician will determine which is the best/most comparable one for you. If your inhaler has a new mechanism, you can find videos on how to use them under the Patient Education tab in the top menu.

  2. Check the website GoodRx.com and type in the name of your medication and the dose. This will give you a list of different pharmacies with their negotiated cost for the medication without using insurance and without needing a PA. Please call our office and ask for the specific medication and the preferred pharmacy (this may be different from the pharmacy we have on file for you).

  3. If you would like us to pursue a Prior Authorization for your specific medication, please be aware that this process may take 4 weeks or longer. Your insurance company or pharmacy may have informed you this is a ‘simple’ process that only takes 1-2 days but, in reality, the process if far from simple. We average 8-10 new PA requests per day (and a current backlog of nearly 200). Each one has its own form to complete with need for specific information from your medical record. We have hired staff specifically to complete the task of obtaining Prior Authorizations (which is not reimbursed by insurance companies) but, despite all efforts, continue to have a prolonged wait for these necessary medications.

    Additional information needed to help with PA requests:

    1. Make sure our office has updated copies of your insurance card
    2. Schedule timely follow up visits with your prescribing physician (insurance companies will refuse PAs for not following up in office)
    3. Make note of PA approval expiration dates (typically one year) and call the office for a renewal request at least 3-4 weeks prior