I need to refill my prescription and I was told that I need a prior authorization. Why does the insurance company need it? I still have hemophilia!
Dear Awaiting Approval,
That’s a great question, and I can understand your confusion! While bleeding disorders are a chronic medical condition for which there is no cure, unfortunately, prior authorization is a cost-containment hoop that insurers still require patients to jump through.
Prior authorization, also known as preauthorization, prior approval, or precertification, is a cost-containment process implemented by health insurers to determine whether they will approve coverage for a treatment plan or prescription drug. If the insurer denies approval, but the patient wishes to follow their doctor’s treatment protocol, the patient will have to pay for the treatment or procedure out-of-pocket.
Insurers originally argued that prior authorization requirements were needed to discourage doctors from prescribing new, pricy brand-name medications in place of cheaper, equally effective alternatives. But in recent years, health plans have expanded the scope and frequency of their prior authorization requirements far beyond those boundaries.
Insurers now commonly require repeat prior authorization for most expensive medicines, and even for generic medications for which no cheaper effective alternatives exist. Frequency of the prior authorizations needed can vary depending on state laws – for some, prior authorization is needed every month, while with others it’s only required annually. It’s important to speak with your provider to see how regularly your prior authorization needs to be completed.
For more information on prior authorization, read our prior authorization policy one-pager.
What Can You Do?
- Be proactive! Check your insurance plan to see if any of your medications require prior authorization. Work with your doctor to ensure they are seeking prior authorization with your insurance company. Start the process early to allow time for the prior authorization to be processed.
- If prior authorization requirements are delaying or blocking your access to medications or treatment, please let HFA know at Project CALLS. Your story can help HFA educate lawmakers and advocate for policy changes that will benefit the bleeding disorders community.
Have a question? Email us. Your name will be changed in the response.
HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed “Dear Addy”. Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance.