Pharmacy Benefit Plan Requirements aka ‘prior authorization’ (Copy)
When a pharmacy informs you that the doctor needs to “authorize” a prescription, this refers to either:
A prescription that has expired. The pharmacist requires a new prescription in order to refill the one that has expired. Or,
Your pharmacy-benefits plan has not authorized payment. In other words, I have authorized a prescription, but your insurance has rejected payment.
Before contacting me, please ask if they are in need of a new prescription, or if the claim (for payment) has been rejected.
If the claim has been rejected, I will investigate the cause (there are several reasons plans may reject a claim but they all boil down to cost-savings). In many cases, the plan may authorize payment if I complete requirements that they have established (some drugs are simply not covered, termed non-formulary).
There is a minimum fee of $65 based on the most common amount of time that will be required, 15 minutes. If the requirements are expected to exceed 15 minutes, I will notify you and get your approval before proceeding as every additional 15 minutes is also $65.
Alternatively, your plan may have a ‘preferred alternative’ on their formulary (a formulary is a list of all the drugs covered by the plan, and any requirements for coverage updated annually). You will have to obtain a copy of your plans formulary (almost always available online to you), and we can discuss which, if any, are appropriate substitutions. There is no fee in this case.
I sincerely wish I did not have to charge a fee for this process, and even more that it was not necessary. But, satisfying plan requirements adds up to a significant amount of time weekly (this is a favorite cost-savings measure of plans), that is otherwise lost income that I cannot sustain. Further, plans will require that this process be repeated every 12 months, unless they move the drug into a preferred category; regardless of how long you may have been taking it or how much benefit it has provided.
Please feel free to bring any questions you have about this process up during future visits. +Dr. Argiro