Prior Authorization Policy

What is a prior authorization?

A prior authorization is an extra step that some insurance companies require before they decide if they want to pay for your medicine.

What is the purpose of prior authorization?

“Cost-containment.” In other words, to increase profits. Insurance companies are restricting coverage to reduce their costs. Methods used include implementing or increasing patient co-payments or coinsurance, restricting use of out-of-network care providers and choice of hospital, requiring prior approval for some diagnostic and surgical procedures, and eliminating coverage for experimental treatments. For the pharmacy benefit, cost containment methods include implementing or increasing patient co-payments or coinsurance, formulary restrictions, setting quantity limits, incentivizing generic drug use, and implementing prior authorization.

How does the prior authorization process affect the clinic?

Every prior authorization we receive goes through a multi-step process that involves a review of the patient’s chart, medical assessment and decision-making, and requires staff time filling out forms and chart documentation. Processing a prior authorization involves much more than just a quick glance and a signature.

What is your policy on prior authorizations?

Our office will only honor prior authorization requests from the patient. The patient will be responsible for contacting their insurance company to have them forward the prior authorization form to our office.

The patient will need to ask their insurance company what “alternative medications” are covered on their plan. There will be a $15.00 administrative fee for completion of a prior authorization form. Medication changes will not be done over the phone and if a medication change is requested the patient will need to make an appointment with their physician.