BENEFIT MANAGEMENT: PRIOR AUTHORIZATION & STEP THERAPY

“The pharmacy told me that the drug my doctor prescribed is covered under my plan but the plan won’t authorize it until I try another drug first.”


pillsWhat is prior authorization?

When your health insurance plan requires approval for certain medical services or treatments before the services or treatments are rendered, this is called prior authorization. Prior authorization requirement will vary from plan to plan.

What is step therapy?

Step therapy is a requirement that less costly and less risky treatment alternatives be explored and deemed unsuitable before more uncertain or expensive therapies are approved.

Why do some companies require prior authorization & step therapy?

Insurance companies use benefit management as a way to ensure that the prescribed treatment is medically necessary. In other words, the insurance company does not want to pay for a medical procedure that is not really needed.

Through prior authorization and step therapy, your insurance company can learn more about your health condition and why the treatment is needed before they decide whether to cover or pay for it.

How do I obtain or know if I need to obtain prior authorization or approval?

Because each insurance company has a unique prior authorization process and step therapy process, the only way to know if your insurance company requires approval for a particular treatment beforehand is to call and ask. Get started now

 

Contact us with insurance questions, success stories or suggestions.
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The National Organization for Rare Disorders (NORD) awarded PHA the Abbey S. Meyers Leadership Award in 2012 for outstanding service to PHA members in advocacy, education and other key areas.