RA Medication and Prior Authorization
If you’re a veteran patient or you’ve been on certain medications before, you’re likely familiar with the concept of prior authorization.
Prior authorization is a somewhat daunting, hardly logical process used by many insurance companies to determine if they will cover more costly medical things - like tests, procedures, services, and medications. In theory, this process acts as a safety measure for insurance companies, but ultimately as a patient I feel like it’s just costly and time-consuming.1
Prior authorizations hold me back
I have been stopped by prior authorizations too many times. For example, when it comes to certain lab tests my doctor wants to run, or diagnostic testing done by my doctor or in an emergency room setting (ie: CT scan or MRI), and most frequently, in renewing my biologic prescription.
For the last 4.5 years, I’ve taken the biologic Remicade. When it was first prescribed, it took my insurance 42 days to approve the prior authorization request for my doctor. I was in a significant flare at the time of transition, and spent much of that time in bed, in the hospital, and overall miserable.
My dose changed a few times that year in order to help my body find remission, and each change required a new prior authorization from insurance. In addition, I’ve been carried by 3 different insurance carriers since beginning Remicade and each carrier and each new year comes with a new prior authorization.
Here we go again
Because I’m currently in the process of requesting a new prior authorization for my biologic in relation to another insurance change, I thought this was a good time to answer a few questions about prior authorization.
How do I know if I need prior authorization?
Well, this is a good question. Unfortunately, there's no straightforward answer. Your doctor should be the one to tell you if a test, procedure or medication they prescribe may be met with additional insurance scrutiny, but to be honest, many of them just aren't familiar with the intricacies of insurance or forget to mention something during your appointment. Then, the nurse or insurance coordinator at your doctor's office should tell you while they schedule you or help you navigate logistics - but I know that not every office has this and not every department or employee is knowledgeable and/or helpful.
Usually, you'll hear this from your insurance. Occasionally it will be via phone or electronic portal, but often via US mail when you're not expecting it and when you're waiting to go for your test or pickup your medication.
Who files for it?
More often than not, this needs to come from your doctor's office or the facility in which you are trying to receive testing/procedures. One notable exception from this is for infusion based biologic medications. I've found that some infusion centers or providers will file the prior authorization on your behalf - but it can require many, many questions and/or follow up on your part depending on their efficiency.
Waiting for approval: How long is too long?
If you're in urgent need of a test, procedure, or medication dose, and prior authorization is standing in your way, then it's time to be more vocal. Call your doctor's office, your pharmacy, your infusion center, your patient navigator/coordinator, your insurance. Call anyone that will listen and put on your firmest voice because your health likely depends on it.
Have you ever been tripped up by prior authorizations? I'm really interested to hear your experiences below.
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