Prior Authorizations for Medication

Prior authorization (PA) is a process used by health insurance companies to determine if they will cover a prescribed medication or treatment. It’s an extra step that requires the healthcare provider to get approval from the insurance company before a specific medication, service, or treatment can be provided. The goal is to ensure that the prescribed medication is medically necessary and appropriate for the patient based on the insurer’s guidelines.

Psychiatric medications that often require prior authorization (PA) typically fall under categories

that are more expensive, require special clinical justification, or are prescribed for off-label uses.

Prior Authorization Process

1. Nurse Practitioners send the prescription to pharmacy

2. Insurance company reviews the request to determine if the medication meets the criteria for

coverage

3. Pharmacy will send the Prior Authorization form to NP

4. NP receives the form and process

5. NP send completed form to the insurance plan

6. Insurance plan alerts the pharmacy and NP if the medication was approved/denied

Handling clients with prior authorization (PA)

When communicating to clients that a medication requires prior authorization (PA), it's essential to

approach the situation with clarity, empathy, and transparency. Patients may feel frustrated or

confused about this additional step, so it's important to explain the process and manage their

expectations.

- Acknowledge the Situation and Express Empathy

- Explain What Prior Authorization Is

- Outline the Next Steps

- Manage Expectations Regarding Timelines

- Offer Support Throughout the Process

Sample Script

“Hi [Client Name], I wanted to inform you that your insurance company requires prior authorization before they will cover the medication your doctor has prescribed. This means that your Nurse Practitioner will need to submit additional information to your insurer to confirm that the medication is the best option for your condition. It typically takes about 3-5 days for the insurance company to review the request, but there can sometimes be delays. I’ll keep you updated on the status, and if there are any issues, we can explore alternative options. Please don’t hesitate to reach out if you have any questions or concerns.”