How To Obtain Prior Authorizations
“The first time I had to get a prior authorization, I was so confused! I thought my doctor giving me a prescription was authorization. Frankly, I was intimidated by the paperwork. Now, I know that it just takes a few extra steps. I put it on my to-do list and do one step a day so it doesn’t get overwhelming.”
—T1D patient, IN
In this section we’ll discuss
What is a Prior Authorization?
A prior authorization (PA), sometimes referred to as a “pre-authorization,” is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure. Many times, this involves your doctor completing a form to illustrate to your insurance company why the insulin, insulin pump or continuous glucose monitor (CGM) you are prescribed is medically necessary. Your insurance company will have requirements that need to be met before it will agree to cover the specific item or treatment.
Why Are PAs Important to Understand?
It’s helpful to understand the steps that you need to take to gain access to coverage for the prescriptions and treatments you use to help manage your type 1 diabetes (T1D). Each plan is different, so while one health insurance plan may not require a PA for your treatment, another plan—even one from the same insurance company—may. Check your insurance plan policy documents before starting the process to understand if a PA is required. Also, the exact content of the PA request may vary from point to point. For example, obtaining PA for a pump may involve supplying different information than obtaining a PA for a continuous glucose monitor.
How Do I Get Prior Authorization for a Medication?
The steps below are the main points in the prior authorization process. Every plan has a slightly different way of doing this, so make sure to check with your insurance company for those details.
- Check your plan’s policy documents and formulary to see if any of your treatments require a PA. You may find these on the plan’s website. If you have Medicare coverage, check your Medicare & You handbook for more information.
- If a PA is needed, locate the process for submitting and obtain any required prior authorization forms. This information is typically found on the plan’s website, or you may call the member services number found on the back of your insurance card.
- Because your doctor’s office is responsible for submitting PAs, it will be important to work with your doctor, or the staff member in the doctor’s office designated to handle PAs, to ensure they have all the necessary information.
- Ensure that the PA request is submitted according to the plan’s guidelines, and double-check that you meet all requirements before they are submitted.
- Once your request is submitted, the insurance company may approve or deny it. If it is approved, you will be able to receive the requested treatment. Be aware that the approval letter may include rules about how you obtain the care. If so, you will need to abide by those terms to be covered.
If the request is denied, you should plan to appeal the decision. More information on the appeals process is provided in Section 5.
Helpful Tips for How People with Diabetes Can Successfully Obtain a PA:
Take an active role and work closely with your doctor or the contact at your doctor’s office to ensure they have the needed information. They will also need key dates for submitting the requests, so be sure to share that information as well.
- Identify who at your doctor’s office handles prior authorizations. Having a good relationship with this representative may help create a smoother process for getting your request approved.
- Ask your doctor for success stories of patients who have had similar requests. This could help guide how you develop your request.
- Someone in your doctor’s office likely has an existing pre-authorization process and knows the typical steps. You may find those details helpful in understanding the next steps and likelihood of success.
- Your doctor’s team may have an approach they use to show the medical necessity of a treatment. Work together to include information that illustrates how the medication or treatment is medically necessary for successfully managing your type 1 diabetes. A denied request may have direct implications for a patient that create problems. This could include not being able to comply with new treatment guidelines or having to pay for a medication out-of-pocket. Changing medicine may lead to even more expensive treatments and emergency room visits. These points may help you show why the desired medication or treatment should be covered.
- Please note, sometimes your doctor’s office will need to work with a supplier who is under contract with the manufacturer of your medicine.
- And lastly, your doctor will likely know the appropriate next steps to take if your insurance company denies your request. They may also know ways that they can help reverse that decision.
- Be sure the prior authorization form is completed in its entirety before it’s submitted. Many PAs are denied because the form is not completed accurately or in full.
- When speaking to insurance representatives, remember to take notes including the date, time, number called, representative name and outcome of the call. It is important to have as many details as possible should you need to follow up with questions or additional needs.
- Review the PA form in advance of meeting with your doctor to ensure you know the necessary criteria and information needed to complete the form. If you have medical information from another doctor that is being used to support your request, like a lab result, make sure to bring that with you.
- To supplement the form, consider providing additional data or evidence, such as lab results that meet criteria or peer-reviewed published articles supporting your request. You can also search for articles yourself using the PubMed database and other online sources. In addition, you could quote relevant information or clinical guidelines that support your request, such as points from the American Association of Clinical Endocrinologists, the American Diabetes Association, and the Endocrine Society.
- Once you are notified that your PA has been approved, keep records of when it expires and remember to begin the process of getting a new one at least a month in advance of its expiration.
Be mindful of timing
- Start the process early. This will help you avoid a delay in medication or treatment.
- Know the key dates for when your information needs to be submitted. Often, insurance companies have strict deadlines for PAs. Often, insurance companies have specific expectations for when the information needs to be submitted, and knowing those key dates is important.
- An expedited approval process is likely available if your need is urgent or time-sensitive. Consult your plan documents or talk to a member services representative or your doctor’s office staff to find out what is needed to obtain an expedited approval.
- Insurance companies will sometimes authorize a short-term supply (e.g., three days to a week) of a prescription while a PA is in process. Don’t hesitate to ask if you need a short-term supply.
JDRF maintains a forum where insurance issues can be discussed.
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