Does a doctor have to pre-authorize prescriptions with the insurance company?
Health Insurance
My doctor’s office refuses to pre-authorize prescriptions with the insurance company. When I go to the pharmacy, the prescriptions then can’t be filled. So I end up paying for the insurance coverage, the doctor’s office visit copayment, but can’t get the medication. Do I have any recourse other than to change my primary care physician? I’ve tried talking to the insurance company, but they say all I can do is file a complaint. Does the dept of banking and insurance have any jurisdiction over the doctor offices’ non-compliance with the insurance company’s contract?
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You should just pay for the medication. It’s stupid to go without the medicine because your insurance won’t pay it.
Buy the medicine you need, and then complain, or change doctors, or change insurance company.
A doctor doesn’t have to preauthorize anything, he doesn’t have to cooperate with insurance companies, he doesn’t have to accept insurance at all.
Dr’s never call for prescriptions, they do call your insurance co to authorize referalls and procedures. They do want to get paid.
When a doctos prescibes medicine you should ask to check if it is covered under your plan. He can do this fairly quickly and most doctors already know which meds are covered.
If it is not covered you can ask him to prescribe a similar medicine that is covered or just pay out of pocket for any medicines not covered.
You could still call your doctor, after the fact, and see if he will give you a new prescription.
You can request a different medication or see a different doctor. Your insurance company will not pay for the prescription unless it has PA from the doctor. I do not believe that your doctor is obligated to prior-authorize any medication. Other than that, I don’t see any other way around it.
It is unfortunate that you had to pay for the visit and in addition pay full price for the medication. However, your doctor had no idea that your insurance company would request prior authorization when he wrote you the prescription. In the future, always know what is covered under your insurance plan so your doctor can prescribe a medication that will be covered under your insurance.
I just went through this last week, if the medication has to be pre-authorized (meaning it’s not on teh insurances formulary list) it is your doctor’s responsability to fill out the paperwork and get it to the Insurance company. My doctor filled out the paperwork sent it to insurance and i got my scripts paid for in 2 days. it’s not that hard a receptionist can fill the paper and the doctor sign it, along with a copy of your insurance card. If they don’t want to do it change offices and find a doctor that is helpful not hurtful to your pockets!
I don’t know of ANY doctor that ‘preauthorizes’ prescriptions. They aren’t required to do that by their “contract” with the insurance company.
Tell your doctor you want something that comes in a generic, or something that’s been out a few years – not something the pharmaceutical rep just told them about last month. Most of the “standard” generics are going to be covered.
Worst case scenario, print out the list of Sam’s Club $4 prescriptions – it’s EXTENSIVE – and tell him you want him to find something on that list that will work.
Most insurance companies don’t have that many pre-authorization medications. They tend to be things like Clarinex, Protonix, and very expensive medications. When needed, it is not a hard thing for a doctor to do. All they have to do is to fill out a form saying you need this drug because the preferred drugs don’t work.
You can contact your insurance company to find out the preferred drug.
I always hated those doctors who would refuse to fill out the pre-authorization forms.
What do you mean by “pre-authorize” prescriptions? Unless you’re getting a brand-new medication, one that’s being prescribed for something other than it’s intended use (like a diabetes drug for weight loss purposes) or one that’s REALLY absurdly expensive (hundreds of dollars a month), or not one that’s regularly covered, those are usually the only ones that require pre-authorization.
Otherwise, your doctor could be writing for things that are not on your plan’s specific formulary – which is a list of medications that are covered by your plan. It’s not impossible that they’re prescribing things that aren’t on the formulary – because some plans change their covered medications the way most people change socks. BUT, unless there’s a reason for that specific medication to be dispensed exactly as written, there’s almost always substitutes for the prescription because almost every plan covers some form of every medication out there. AND if that’s the case, your pharmacist should be more than willing to call the doctor’s office to request the substitution. (It’s usually a simple yes or no.)
If you really feel you have a complaint, you can file with your state’s insurance board (google the one for your state) and they’ll investigate. But, perhaps your beef should really be directed at your insurance company – nobody regulates them and they do whatever they please.
Generally the only time a prescription needs prior authorization with the pharmacy is when it is a brand-name medication.
If there is a generic equivalent that you can take, it should bypass this problem. Or, check to see if there are other alternate brand name drugs you could take – sometimes its one specific brand name that triggers an authorization (perhaps its not on your formulary, etc.), while another brand name might not trigger an auth request.
some doctors will take the time to be aware of what meds are ‘covered’ under insurance and which are not
your doctor really does not seem to care, but I bet if you go back to the doctor’s office they will be able to change the prescription to one that is covered
an alternative that i have done is order some meds in generic form from the online pharmacy site below, quite often these generics are cheaper than the insurance copays
bottom line, either push your current doctor to give you a perscription that is OK with your insurance company or find another doctor
Very few doctors do this. Try asking the pharmacist about alternatives that your insurance does cover. That’s their job. If the pharmacist has any question, they will call your doctor to make sure the switch is okay.
First of all I want to correct some answers given. Doctors call insurance companies all the time to get what are called prior authorizations done for certain medications to be covered on patients insurance plans. The problem is that this process can take several days in which the patient is without medication. Secondly it is not the job of the pharmacy to find out what medication is covered by someone’s insurance. The doctor is provided a list of covered medications and they just won’t take time to look them up. The patient can call the toll-free number on their insurance card and ask them what medication is covered in certain classes such as ulcer medication, etc. Then let the doctor know what should be prescribed. Everything is not the responsibility of the pharmacy. The patient can do a little work to save themselves hundreds of dollars on some of their own prescriptions that are not covered.
To those who think it is so easy for the drs’ office to preauthorize medication, think again. Drs write MANY prescriptions daily and Drug insurances frequently want preauth. Drs would need to hire a full time person just to take care of that alone. Drs dont get paid as well as people think. Writing substitutions are the easiest way to go. The real problem is when there are no substitutions. Also sometimes the pharmaceutical company will mail samples to the patient if they qualify. But it is unfair for Drs to now take on medication payment issues along with their own office insurance obligations.