What is a prior authorization?
Under medical and prescription drug plans, certain services and medications may need approval from PCHP before they’re covered. This approval is called a prior authorization, and your doctor will work with PCHP to get this approval for you.
What types of medications typically need approval?
Those that:
- May be unsafe when combined with other medications
- Have lower-cost, equally effective alternatives available
- Should only be used for certain health conditions
- Are often misused or abused
- Are often used for cosmetic purposes
Medications that require approval will only be covered by your plan if your doctor requests and receives approval from PCHP.
What types of services typically need approval?
Your doctor and PCHP can tell you if the services you need will require prior authorization. You member handbook is also a good resource and lists limitations and exclusions for your health plan. Generally, these services may require prior authorization:
- Durable medical equipment
- Home health
- Private duty nursing
- Rehabilitation
- Surgery
- Therapy
Refer to your member handbook or call Member Services if you have questions about services requiring prior authorization.
What’s the difference between prior authorization and pre-authorization?
None; these terms mean the same thing and are used interchangeably. However, most insurance companies will use the term “prior authorization” instead of “pre-authorization.”
How does the prior authorization process work?
Prior authorizations are handled by your doctor’s office and PCHP. We will contact you with the results to let you know if your medications or services have been approved or denied, or if we need more information.
If you are unhappy with your prior authorization decision, you or your doctor can ask for a review of the decision. In the case of denials for prescription drugs, your doctor may choose to prescribe a different but equally effective medication. In some instances, PCHP may recommend you try an alternative medication that’s less costly, but equally effective, before the medication your doctor originally prescribed can be approved.
Learn more here.