How Prior Authorization Helps

How Prior Authorization Helps

Prior Authorization helps make sure prescription medicines are being used safely, as intended and at the best cost. Only a handful of drugs need prior authorization, also called pre-approval. Those are often the ones that cost the most or the ones that are not safe when not used the right way.

It’s one way for your doctor and health plan to make sure you are taking the drug safely. Here’s why we need to approve some drugs before a prescription can be covered by your plan:

  • Member Health and Safety
    Drugs that are unsafe when used with other medications may need prior authorization. Some drugs that are FDA-approved for one health condition but being used to treat another may need review. So are often misused drugs. You can find out if your drug needs prior authorization.
  • Plan Benefits and Drug Lists
    We’re following the rules of your health plan. What needs prior authorization can be different for each plan or drug list. A prescription drug list is also called a formulary. It’s a list of drugs, set up in levels of coverage called member payment tiers. The lower the tier, the lower your out-of-pocket costs will be for the drug.
  • Regulatory Concerns
    Some drugs require the doctor and/or the health plan to follow detailed rules. The Food and Drug Administration regulates the dispensing of controlled substancesleaving site icon Those are habit-forming and carry a high potential for harm. One case is opioids for pain control. If not used the right way, they can put a patient at risk for opioid use disorder, overdose and death. So the Centers for Disease Control and Prevention issued specific guidelines for useleaving site icon
  • Costs
    Prescriptions are a growing part of the overall cost of health insurance. For each $1 of health care premiums, prescription drug costs were 22.2 cents, says AHIP leaving site icon (America’s Health Insurance Plans). Costs for hospital care was 19 cents. Out-patient hospital care costs 19.9 cents and emergency care costs 3.3 cents. Doctor visits accounted for 11.8 cents and the rest was taxes and fees. Keeping prescription costs down (without compromising health or safety) affects the monthly premiums of all members. The U.S. spends more on prescription drugs per person than any other country, says the Blue Cross Blue Shield Associationleaving site icon

Learn more about Pharmacy and Prescription Plan Information.

Sources: Federal Regulation of Medication Dispensing, leaving site icon National Library of Medicine, 2023; Applying the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain, leaving site icon Centers for Disease Control and Prevention, 2023; Your Health Care Dollar:  Vast Majority of Premium Pays for Prescription Drugs and Medical Care, leaving site icon  AHIP, 2022; 7 solutions for prescription drug costs, leaving site icon Blue Cross and Blue Shield Association, 2023