Prior Authorization

WHAT TO KNOW

What is Prior Authorization?

Before a patient can receive a particular prescription medication, doctors must submit information to the insurance company detailing the patient’s specific need for the medication. Once the insurance company has received the doctor’s justification, they will approve the medication and the patient can receive his or her treatment.

What is the purpose of Prior Authorization?

Prior authorization is a tactic that insurance companies use to contain health care spending. Insurance companies apply prior authorization procedures to certain high cost medications. They do this to ensure that a prescription is medically necessary before agreeing to pay for it.

Does the current system of Prior Authorization hurt patients?

Yes. Many patients incur a long waiting period before they begin necessary medications.

Doctors are frustrated by the system and it is a tedious/confusing process to navigate.

• According to a recent study, the average physician practice devoted 1 hour of physician time, 13.1 hours of nursing time and 6.3 hours of clerical time to the prior authorization process each week 1.

A streamlined system would ensure timely treatment for patients and physicians’ time devoted less to paperwork and more to direct patient care.

What does prior authorization legislation try to accomplish?

The type of legislation we advocate for is aimed at implementing a streamlined and standardized process to submit prior authorization information and shorten the time between when a patient is prescribed a medicine and when they begin treatment.