Sometimes, a health insurance carrier may require additional paperwork from your provider before covering the cost of certain types of medication. This process is called prior authorization (also called pre-authorization, pre-certification, or prior approval).
Health insurance carriers tend to require prior authorization based on a few factors, including:
- The cost of medication
- Availability of less expensive, alternative medications
- Drugs limited to treating specific health conditions
- Medications they include in their formulary (a list of drugs they cover)
Unfortunately, it is not uncommon for medically necessary weight loss medication to require prior authorization. Prior authorization can take time because your insurance carrier, provider, and pharmacy must all coordinate. These are the typical steps involved:
- Your pharmacy receives your prescription and tries to process it with your insurance.
- If required, your insurance notifies your pharmacy that prior authorization is needed.
- Your provider contacts your insurance company and submits documentation for your treatment. Documentation includes: your medical condition, other medications you have tried, safety, and why this medication is appropriate.
- Your insurance carrier reviews these documents and may approve, deny, or request additional information.
- Suppose the request for prior authorization is approved. Your insurance will cover the medication cost, but that coverage will depend on your plan's benefits. (A co-pay may still be required, even with approval.)
If your health insurance denies the request for prior approval, they will not cover the cost of your medication. You can still choose to pay cash (out of pocket) for medication. You may also be able to work with your provider to proceed with an alternative medication that is on your health insurance’s formulary.
If your health insurance requests prior authorization, please allow 15-25 business days for your provider and pharmacy team to submit all the necessary documentation.
See the following FAQ's for more information: