My Prescription Drugs Need Prior Authorization, Now What?

My Prescription Drugs Need Prior Authorization, Now What?

I’m trying to pick up my new prescription, but now my pharmacist is saying I need a prior authorization approval.  At first I thought I might lose it because I thought I couldn’t get my drugs.  But, after talking with my pharmacist, it all made sense.

Here’s what I’m told about prior authorization programs:
My doctor will need to send a request form to my insurance company for approval.  If the prior authorization request is approved, I’ll pay for my share of the drug using my prescription drug benefit.  If it isn’t, then I have to pay all costs myself and can't use my prescription drug benefits.

Or, I can always ask my doctor if there is some other drug that might be right for me.

Here’s what I learned about why only certain drugs are in the program:
Prior authorization is meant to promote safe, cost-effective drug use. Only a handful of prescribed drugs (those that are costly and often misused) need this pre-approval. Prior authorization is a way for your insurance company and your doctor to make sure you are taking the drug safely and in the best way.

What needs prior authorizationTake it from me, you’ll have to pay the full cost for your prescription drugs if the prior authorization request hasn’t been sent and approved.  And those prices are never fun to pay alone.

Here’s some tips to follow before going to the pharmacy:

  • Ask your doctor if a new prescription needs prior authorization – every time.
  • Know as much on prescription drug prior authorization as you can – starting now.  Get started!  
  • Look up your drug on the MyPrime website:
    • Visit Blue Access for MembersSM (BAM):
    • Select Prescription Drugs in the Quick Links box (right-hand side).
    • Once on the MyPrime site, search for your meds in the “Find Medicine” section.

Note:  If your drug needs a prior authorization, a special requirement notice will appear.

If your prior authorization request is approved, it is approved for a fixed amount of time, usually six months or up to a year. So, you will not need to submit a new request with every prescription fill.  Before your prior authorization approval will expire, you may be notified up to 45 days before that date (for most requests).  These alerts are sent by letter, but you can sign up to get them via email or text message on the website, under the communications preference on your profile.

Originally published May 26, 2015; Revised 2019