Why Your Medication Needs Prior Authorization, and What We Do About It

If your doctor has ever told you a medication "needs a PA," here is what that means and what happens next.

A prior authorization is a form we send to your insurance company explaining why you need the medication your provider prescribed. Insurers require it for medications that are expensive, need special handling, or need monitoring while you take them. Most specialty medications fall into all three categories.

Someone asked me recently whether I could think of a prior authorization I had to fight for. That is every PA. So we built a team around it.

What the process looks like from your side

Your specialist writes the prescription and sends it to us. Usually they tell you in the office: this one needs a PA, we are sending it to our pharmacy, they will take care of you.

From there, our team takes over, together with our partner CarepathRx, which supports the clinical side of the work: the authorization, counseling and shipping logistics. Our staff on site handles the insurance and billing. Our turnaround is typically 24 hours. For a complicated case, you will hear from us within a week. Either way, you hear from us. We let you and your provider know whether the insurer approved or denied it, and if it is denied, we tell your provider what the insurer prefers instead.

Once it is approved, we call you to set up pickup or delivery. In most cases you have the medication in hand within about 48 hours of the prescription reaching us.

Why that fast? Because we have access to the hospital's electronic medical record. We do the authorization with your chart in front of us, not waiting on a fax from someone else's office. My colleague Beauman Dick wrote about what that access means for every pharmacist at Nashville General.