Insurance Battles: The Struggle Is Real
Warning: This probably isn’t the most entertaining post, but it’s a topic that comes up a lot this time of year. Plus, I’ve been slacking a bit (read: a lot), so I figured I might as well start somewhere.
Why This Post Matters
There are few things I loathe more than insurance companies. I could say a lot about them, but today I want to talk about something many patients run into: Prior Authorizations (PAs) for medications.
Over the years, I have learned a lot of tricks and strategies while advocating for myself, my family, and my patients. And honestly, there is a strange rush of satisfaction when you finally win a battle with insurance. I imagine it is akin to reaching the top of Mount Everest- although I don’t think climbing a mountain involves spending hours on the phone and/or writing impassioned letters demonstrating medical necessity…
What Is a Prior Authorization?
If your pharmacy ever tells you that they are “waiting for something from your provider” or “waiting on insurance,” it is often because a PA is required. Essentially, some medications are more expensive and insurance wants proof that they are medically necessary before they agree to cover them.
How the PA Process Works
Here is what the process typically looks like:
Your provider sends a prescription to your pharmacy.
The pharmacy runs the prescription through your insurance, determining the cost and if a PA is needed.
If a PA is needed, the pharmacy usually initiates the request and sends it to your provider.
This step usually occurs via fax or electronic portal. If the pharmacy tells you they’re waiting on your provider or insurance, sending a quick message to your provider can help ensure that the request does not get lost in the system- technology loves to fail us at the most inconvenient times.
Your provider completes the PA and submits it to your insurance.
This typically involves your provider sending additional information such as:
Medical records
Previous treatments and response
Documentation explaining why this specific medication is necessary for you
Insurance reviews the request.
This can take up to 72 business hours or longer depending on the insurance company
A decision is sent to your provider and the pharmacy
If the PA is approved, it means that your insurance will cover the medication. However, this does not necessarily mean that it will be free- you may still have a copay or need to meet your deductible before your insurance will pay for all or a portion of the cost.
Why PAs Are Denied
If a PA is denied, the insurance must provide a reason.
One of the most common reasons for denial is called "step therapy." This means that the insurance company requires you to try and “fail” other medications before they will cover the one originally prescribed (don’t even get me started….).
Another reason medications may be denied is because they are being used off label- meaning there is evidence supporting their use for a condition, but the medication has not officially been FDA approved for that specific diagnosis.
What You Can Do if a PA is Denied
You should receive a denial letter explaining the reason and sharing your options. These usually include:
Trying an alternative medication that is covered by your insurance
Your provider submitting an appeal
Submitting your own appeal as the patient
It’s important to know that an appeal usually needs a specific reason. We generally can’t just resubmit the same request and hope for a different outcome. Appeals typically require new or clarified information justifying why the originally prescribed medication is medically necessary and why the covered alternative medications are inappropriate.
I have worked with patients who successfully appealed decisions after my appeals were denied- and I’ve done the same with advocating for my own child. Sometimes patients can provide additional context about side effects, past treatment, or how their symptoms impact their daily life in ways that strengthen the case.
TL;DR:
Insurance can be frustrating, but your provider is on your side. The process can take time and involve back-and-forth, but every effort is made to provide the documentation and information needed for the insurance company to approve the medication. Sometimes it takes persistence, but those efforts can make a difference.