Prior-Authorizations are for medications that your insurance is requesting documentation for, such as “why you need it”, “why its being prescribed” and or its no longer covered on your formulary.
The most common medications that require authorizations are Testosterone products (Androgel, Testim, Axiron), HIV medications, and Erectile/BPH medications.
Medications requiring prior authorizations do take longer (up to 14 business days) to process. Pharmacies are responsible for sending us the Authorization request to 888-294-3708 if we DO NOT receive the request, we won’t know you need one. The reasoning behind this is that the request they send us has all your pharmacy benefit information on it. For example, your insurance may be UnitedHealthCare and or Florida Blue (BCBS) but your pharmacy benefit with them is OptumRx or PrimeTherapeutics which are completely different then your medical benefits.
PA’s are done electronically via CoverMyMeds and are not done verbally over the phone– calling the insurance companies and doing them by phone is not the fastest route and sometimes can delay you getting your medication, especially when you think you have enough medication to last you awhile, but in reality you don’t.
Referrals Authorizations are for medical facilities such as hospitals, physical therapy, radiology and or specialist visits- these are only for HMO type insurance plans. If you have a PPO type insurance plan, they do not require authorizations, only the referral script we give you in the office.
These authorizations take time (close to 2 weeks, if not longer) to complete. Facilities are responsible for sending us the request that you are being seen at their office and what procedures (if any) are being done; this information includes: procedure codes, CPT codes, ICD-10 codes, phone and fax number, the Doctors NPI number along with their tax ID- is HIGHLY important and without it, we cannot start the process which may delay you being seen. If you are seen by that facility and or Doctor, before our office obtains the authorization, we CANNOT backdate these authorizations since they have already occurred and services were rendered.