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Those Dreaded Words: Your Prescription requires Prior Authorization

As the most accessible healthcare provider, the pharmacy team often gets the brunt of the push-back when a patient’s insurance requires prior authorization (PA). Patients do not understand why their insurance gets to dictate their care and more importantly, they just want their ailment taken care of quickly and effectively. In seeking to be part of the solution, instead of the problem, our team has identified several common pitfalls in the process and ways to circumnavigate them.

Standardizing the process

In most pharmacies, the process for submitting a PA is to hit the button to send it to covermymeds® (CMM®) and then wait for some sort of response. In contrast, some technicians also prefer to call the office and let them know about the need for PA. The problem we found was that each technician completed the communication to the provider just a little differently. After identifying the problem, the solution was an easy one, we standardized the process with what was simple and effective. Understanding that not every office utilizes CMM®, our team uses a faxed document that provides patient demographics, insurance information, the reason for the PA, and therapeutic alternatives. The standard process then: complete both the PA form and CMM® for each PA.

Make them visible

Think about your process right now, are you sending the PA off into the abyss of CMM® and hoping you remember to check on it? Are you, like us, relying on an email from CMM®, or a call from the doctor or patient to let you know the resolution? Our solution was to keep our faxed information sheets and put each of them in their own colored basket. The physical presence of the PAs makes the entire team aware of how many we have and gives them a place to reference if a patient calls. We no longer can blame the out-of-sight out of mind for the reason PAs are unresolved.


The delay from their doctor appointment to when they start the medication, sometimes for an acute medication, can be days to weeks in some cases. As pharmacy staff we are often quick to place responsibility on the provider for not doing their part or the insurance for their delays in response but what solutions have we helped to provide. For our team, the answer was a better follow-up. Twice a week a staff member adjudicates the prescription to determine if the PA has been approved. If the claim is still rejected, the team member contacts the office to reiterate other formulary options and/or to check on the status of the PA. This simple phone call often results in resolution without the wait.

Bottom Line

Our team has been successful in cutting our patient’s therapy-free days due to PA in half through three simple concepts - teach the philosophy of why we complete the same standard process each time, make each PA form visible, and schedule follow-ups on them. Lastly, trust your technicians to practice at the top of their ability. Their involvement in this process increases its efficiency exponentially.

Written on behalf of CPESN West Virginia by Moundsville Pharmacy FtP champion, Elizabeth Laughlin, PharmD

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