{"id":6916,"date":"2019-11-19T09:24:54","date_gmt":"2019-11-19T09:24:54","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/pharmacy-billing-services-blog\/?p=6916"},"modified":"2023-06-15T05:00:10","modified_gmt":"2023-06-15T05:00:10","slug":"why-prior-authorization-required-for-prescription-drugs","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/pharmacy-billing-services-blog\/why-prior-authorization-required-for-prescription-drugs\/","title":{"rendered":"Why Prior Authorization Required for Prescription Drugs?"},"content":{"rendered":"\r\n

What is a Prior Authorization?<\/strong><\/h2>\r\n\r\n\r\n\r\n

Prior authorization for prescription drugs is required when the insurance company asks the patient\u2019s physician<\/a> to get specific medications approved. Prior authorization must be provided before the insurance company will provide full (or any) coverage for those medications.<\/p>\r\n\r\n\r\n\r\n

Health insurance companies pre-authorize medications in order to keep healthcare costs low. By ensuring that medication is medically necessary, up-to-date, as economical as possible, and isn\u2019t being duplicated, health insurance companies can afford to provide more expensive medications to those who truly need it.<\/p>\r\n\r\n\r\n\r\n

Why Prior Authorization is Required?<\/strong><\/h2>\r\n\r\n\r\n\r\n

In many cases, prior authorizations are intended to ensure drug use is appropriate and the most cost-effective therapy is being used. For most of the insurance providers, there are three reasons for the use of prior authorization: scope controls, utilization controls, and product-based controls.<\/p>\r\n\r\n\r\n\r\n

Scope and Utilization-based Prior Authorization: <\/strong><\/h3>\r\n\r\n\r\n\r\n

Scope controls refer to constraints used to insure a drug is used for approved indications and is therapeutically appropriate. Utilization controls are used to limit the quantity of medication dispensed or to limit the duration of use.<\/p>\r\n\r\n\r\n\r\n

Product Based Prior Authorization (PBPA):<\/strong><\/h3>\r\n\r\n\r\n\r\n

This program divides certain therapeutic categories of drugs into two or more levels called Tiers. Tier 1 medications are preferred as the first step for treating a member\u2019s health condition. They are cost-effective and are usually available without Prior Authorization. Members that do not achieve a clinical success with Tier 1 medications may qualify to obtain a Tier 2 or Tier 3 medication. Most of these categories are set up so that if a member meets the step therapy criteria, their claim for the next highest tier will process without a Prior Authorization. Doctors who have members with clinical exceptions may request a Prior Authorization to skip the step therapy process and receive the Tier 2 or Tier 3 drug immediately.<\/p>\r\n\r\n\r\n\r\n

What Kinds of Medications Warrant Prior Authorization?<\/strong><\/h2>\r\n\r\n\r\n\r\n

Insurance companies will most likely require prior authorizations for the following drugs:<\/p>\r\n\r\n\r\n\r\n