Prior Authorization, 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.

Each health plan has a different approval process for prior authorization and uses a different form for each medication procedure.

Without this prior approval, your health insurance plan may not pay for your treatment and other options can be explored.

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Example: Drug A (cheap) and Drug B (expensive) both treat your condition. If your healthcare provider prescribes Drug B, your health plan may want to know why Drug A won’t work just as well. If you can show that Drug B is a better option, it may be pre-authorized.

• Your provider writes a prescription which can be paid for through insurance coverage, Rx coupons, medication assistance programs, or sometimes found at a lower cost at one of our Canyonlands pharmacies.
• Occasionally, your insurance tells the pharmacy and/or your provider that the prescription requires prior authorization.
• You and your provider decide if you will choose a different medication or go through the prior authorization process.
• The prior authorization process will require information such as treatments tried, side effects experienced, or other reasons for the chosen medication and can take up to 14 days once submitted. If denied, your provider can appeal with more documentation.

Be sure to follow up with or communicate back to your provider how the medication works for you.

Traditional Medicare does not require prior authorization for the vast majority of services, except under limited circumstances. Medicare Supplement plans follow Medicare’s guidelines to determine if a procedure is medically necessary and eligible for coverage.

Medicare Advantage plans can require enrollees to get approval from the plan prior to receiving a service, and if approval is not granted, then the plan generally does not cover the cost of the service. Medicare Advantage enrollees can appeal the plan’s decision.

Prior Authorization is issued for AHCCCS covered services within certain limitations, based on the following:

• The member’s AHCCCS eligibility;
• Provider status as an AHCCCS-registered FFS provider;
• The service requested is an AHCCCS covered service requiring PA;
• Information received from the provider meets the requirements for issuing a PA number;
• The service requested is not covered by another primary payer (e.g., commercial insurance, Medicare, other agency).