Prior Authorizations

Certain medical services, procedures, devices and medications require your healthcare provider to seek prior authorizations from your health insurance provider before the company covers the cost.

However, a denied request for prior authorization for medication or procedure has direct and dire consequences for you. It may result in your failure to comply with specific new treatment guidelines from your physician or with you having to pay out-of-pocket for your medication.

We can help you avoid such an unfortunate situation. Do not let red tape stop you from receiving the medication you need. Talk to Sustain Meds today, and let us get your prescription approved as quickly as possible.

Prior Authorizations

What Are Prior Authorizations?

According to Healthcare.gov, prior authorization, also known as pre-authorization, is “approval from a health plan that may be required before you get a service or fill out a prescription in order for the service or prescription to be covered by your plan.”

In practice, this often means that your doctor should contact your health insurance company and receive approval from your plan before the company can cover the cost of the prescribed medication, device, or medical procedure.
Often, this involves your doctor filling out forms to prove to the insurance company why the medication, device, or procedure prescribed to you is medically necessary.

Sustain Meds will apply for prior authorizations for your medications and ensure that your prescription meets your insurance company’s requirements. Contact us and let us show you how.


Medications That May Require Prior Approvals

According to Healthpayer Intelligence, about 66% of the prescriptions rejected at pharmacies require prior authorizations. In many cases, the insurance companies consider the drugs expensive, unnecessary, or high risk. They typically include the following classes of drugs:

  • Medicines that users often misuse or abuse
  • Medications that could be unsafe when used alongside other medications
  • Brand-name drugs that have practical and lower-cost generic alternatives
  • Drugs are typically used only for cosmetic purposes

Undoubtedly, there are some benefits of prior authorizations. Still, they are also controversial, with an opinion piece in The New York Times claiming that many physicians and patients are frustrated with how they often place barriers between individuals and the medical help they desperately require.

Prior approvals can complicate matters, particularly if you suffer from a complex or chronic condition requiring ongoing treatment using high-cost medication. Trying to get your medication pre-approved by your carrier may involve your physician or pharmacist repeating the process of pre-authorization multiple times and getting declined before finally gaining approval.

Sustain Meds will help you accelerate the process to avoid treatment delays that could hinder your progress or recovery.

Our Process of Receiving Prior Authorizations

Prior authorizations from an insurance company for prescription medication work like this:

  • Step 1: If your pharmacy receives information from the insurance company that your medication requires prior approvals, they will let your prescribing physician know about it.
  • Step 2: Your doctor or a staff member will then contact you and your insurance company and fill out forms to make a formal authorization request.
  • Step 3: Your insurance company may also need you to fill out some forms or provide documentation before reviewing your approval request.
  • Step 4: Finally, your insurance company will contact you, your pharmacy, or your physician if the request is approved or denied. Once you know the company’s decision, you should contact your physician and let them know.

As you can see, getting prior authorizations is a tedious process that could take ages without any help.

At Sustain Meds, we understand the process of pre-authorization and can help speed up getting coverage for the treatments you need within your healthcare plan. Our team has the experience you need to ensure you get approval or successfully appeal the insurance company’s decision if the company declines your request.

Let us take the hassle of getting prior approval for your essential treatments. Please read our Frequently Asked Questions for more about what we do to ease access to the medication you require.


Sustain Meds Can Help Get the Prior Authorizations You Need

Many health insurance plans require that your physician or pharmacist obtain prior authorization to prescribe medication for you or when they order a service or procedure. If they do not receive the necessary approval, the insurance company may deny your claims for reimbursement, leaving you to foot the bill.

However, it can be tough to track what medication requires prior authorization since it varies from one insurance company to another, from year to year, state to state, or plan to plan. Sustain Meds has a qualified team that understands everything about pre-authorization and has a process to ensure that you successfully get approval for your prescribed medication.

Is your prior authorization taking weeks to get done? Sustain Meds specializes in processing prior authorization forms to achieve the highest success rates and industry-leading process times. Our case representatives submit and monitor the process from start to finish. Contact us today and find out how we can help you get insurance coverage for vital treatments.

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Sustain Meds is a leading Authorized Representative that acts on the patients behalf to ensure their prescription treatment plan issued by the doctor has the best chance of getting through the administrative process.