Here’s a prescription to improve your medication savvy
Your pharmacist will explain the problem when there is an issue filling your prescription. (Stock Photo)

Editor’s note: This is the first column in a series that will continue next week in Health & Fitness.

You’re standing at the pharmacy counter with a new prescription in hand, only to have the pharmacist tell you that your medication needs “prior authorization” or you’ll have to pay the retail price.

“What?” you say. “But here’s the prescription. Isn’t that enough authorization?”

You’d think so, but just as with medical procedures, your insurance company has the authority to step in between you and your doctor when it comes to prescriptions.

What is prior authorization, or PA? It means the insurance company needs to give its OK before it will pay for a medication. If the insurer refuses the authorization, you can still get that medication, but you’ll be paying more out-of-pocket. Much more.

And it can catch you by surprise. CoverMyMeds, a company that offers an electronic prior authorization service for health care providers, estimates that nearly 40% of prior authorization prescriptions are abandoned at the pharmacy.

Avoid time-consuming snags when filling your prescriptions by arming yourself with a little bit of knowledge.

Know your formulary

Every insurance provider has a “formulary” that lists which drugs it will pay for and how much. Just because a drug is in a formulary doesn’t mean it’s inexpensive. Drug plans typically have “tiers,” or levels of coverage, ranging little to no co-pay to expensive coinsurance.

Reading a formulary can be confusing. The medication categories are sometimes hard to decipher. Some drug names are capitalized; there are lots of different dosages and notations such as “PA” and “QL” (for quantity limits); and there may be multiple entries for the same medication!

When you see “PA,” your prescription needs prior authorization.

Tips for affordability

With assistance from Theresa Malvar, a pharmacy consultant I often consult, here are some tips for navigating the PA requirement. Knowledge is power, and we both believe in the power of individuals to manage their health care, on their own or with the help of an advocate.

• Even if your prescription has refills, you may still need to satisfy a prior authorization requirement. Many patients do not understand this process, and when pharmacies try to explain that a prior authorization is required, a patient may respond that they have refills for the entire year. Unfortunately, refills on a prescription do not always match the prior authorization expiration date.

It’s a good idea for patients to keep track of the prior authorization expirations to avoid delays at the pharmacy.

• Try to have your insurer’s formulary handy when you are at a doctor appointment. This can be unwieldy, as formularies can run to hundreds of pages and are not the easiest things to understand. You may be able to search the formulary from your phone. The formulary may indicate that a different tier of the medication doesn’t require prior authorization.

• There’s no easy way of knowing which drugs require prior authorization. Some are name-brand, some are generics. Some varieties of the same drug have prior authorization while others don’t. Also, insurers update their formularies regularly, so the drug you took last year may now need prior authorization. If your insurer changes how it covers a drug while you are taking it, you are supposed to be notified, but it pays to be proactive.

• If you find your prescription has a prior authorization, ask your doctor to find an alternate medication. It’s to the doctor’s benefit to not prescribe prior authorization medications because some insurers require the PA to be renewed every 30 days!

Where to find help

You and your doctor may decide that you need a particular medication. If the insurer refuses to authorize the medication, you’ll have to find ways to pay for your prescription without insurance. You may be able avoid hundreds of dollars in out-of-pocket costs with one or more of these resources.

• The Patient Advocacy Foundation offers a Co-Pay Relief Program for eligible people.

• GoodRx helps people find coupons and discounts for commonly used medications for both retail and mail-order pharmacies.

• The HealthWell Foundation provides grants to cover medications treating particular diseases and conditions. There are income eligibility requirements.

• CoverMyMeds is a resource for health care providers, helping them research and obtain prior authorization approvals electronically. See if your doctor is familiar with it.

Prescription prices are unregulated, so finding affordable options can seem like a game, with you as the pawn. Research — whether you do it on your own or with the help of a patient advocate — will help you stack the odds more in your favor.

• Teri Dreher is a board-certified patient advocate. A critical care nurse for 30+ years, she is founder of NShore Patient Advocates ( You can contact her at (312) 788-2640.