Insurance Issues: Prior authorizations

Navigating the sea of medical insurance can be challenging for patients at times. Insurance companies create guidelines and policies to keep their costs down which sometimes prevent patients from accessing medications, tests, and procedures ordered by their provider.

One method that is used is called a prior authorization. This means that the doctor’s office has to submit evidence to the insurance company to “prove” that a patient qualifies for a specific drug, test, or procedure. They often require step therapy meaning that the insurance company will require patients to try older medications prior to trying ones that are newer (and more expensive for insurance companies). For example, many insurance companies require that a patient try and “fail” (medication ineffective, side effects, or contraindications) medications from the triptan class before being able to qualify for Nurtec or Ubrelvy.

A “workaround” set up by pharmaceutical companies is something called a Bridge program. This is a partnership between pharmaceutical companies and specific pharmacies to provide a new to market medication to patients in an efficient manner at low or no copay. This allows the patient to receive the medication before the prior authorization process is completed. It also allows time for providers to meet step therapy requirements. For example, our office sends Nurtec to ASPN pharmacy which participates in the Bridge program and will then ship the medication to the patient’s home.

For more information about medical insurance issues call the office to speak with our registered nurse Olivia or ask your healthcare provider.

By: Brooke Steiger, NP