Prior authorization (PA) is a tool to control usage, improve therapy outcome, and manage costs.  It is a process that promotes appropriate medication use by approving non-formulary drugs that meet specific, defined criteria.  As a result, PA controls the use of high-cost medications by assuring that lower cost and what’s considered therapeutically equivalent agents are used first.  The FDA defines therapeutic equivalent as “drug products that can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product.”  One example is the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen (Naprosyn) as first-line agents before approving and paying for more expensive COX II inhibitors such as celecoxib (Celebrex).

The PA process can be handled by phone or fax.  Oftentimes, all it takes is a phone call from the doctor’s office to provide the insurance company with information that includes medical diagnosis, previous medication history, and other chart information.  If the PA is approved, you’ll get the prescribed drug.  If the PA is denied, the doctor will prescribe a new formulary drug that is approved for coverage by the insurance or he may insist that you pay out of pocket for the non-approved drug.

As a patient, you may have to wait anywhere from 1 to 3 days to get a medication.  So what do you while you wait for the medication to be approved?  There are several options.  First, you can purchase a few pills until the medication is approved.  Second, some plans may approve a 3-day supply while your doctor works on the PA.  Finally, you may ask for recommendation of other alternatives or over the counter medications that may be used for a few days.  As always, check with your doctor or pharmacist.

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