Understanding Prior Authorization Requests

What is a prior authorization request?

A prior authorization (PA) request is a letter to a health insurance company that asks the company to pay for certain prescriptions before the prescription is ordered. Most health insurance companies need a PA request before it will pay for certain prescriptions. Your child’s doctor will send the PA request to your health insurance company.

Even when a health insurance company gets a PA request, it might not pay for the prescription. Talk with your child’s doctor about your options to make sure you get the prescription your child needs.

How long does my health insurance company take to review a PA request?

Every health insurance company is different. The table below shows about how long different health insurance companies take to process a PA request. If you don’t see your health insurance company in the table, call the member services phone number on your health insurance card. Ask your health insurance company how long it takes to review a PA request.

Some health insurance companies might need more medical information from your child’s doctor before reviewing the PA request. Sometimes, this can slow down the time it takes to approve the PA request. Other health insurance companies might need the PA request to go through durable medical equipment (DME). A DME is a company that sends medical equipment, medications or formula to patients through the mail. Our staff at MGfC will contact the DME that works with your health insurance plan.

Health insurance company	How long it takes to process a PA request	Does a PA request need to involve a DME?
MassHealth®	About 30 days	Yes
Blue Cross Blue Shield of Massachusetts®	About 3-5 business days	No
Harvard Pilgrim Health Care®	About 3 days	No
Mass General Brigham Health Plan®	About 30 days	Yes
Tufts Health Plan®	About 3-5 business days	No
Cigna®	About 30 days	Yes
Aetna®	About 30 days	Yes
UnitedHealthcare®	About 30 days	Yes

How can I learn which prescriptions need a PA request?

There are a few ways to learn about prescriptions that need a PA request. Try the following:

• Read the pharmacy benefit section of your health insurance plan. The pharmacy benefit section of your health insurance company’s plan has a list of all the prescriptions that might need a PA request. This list is called a formulary or preferred medication list.
  
  We’ve found that some pharmacy benefits don’t pay for baby formula. These include CVS Caremark®, Express Scripts®, Medco® and other pharmacies that deliver medications in the mail. If your pharmacy benefits don’t cover baby formula, call your health insurance company. Ask if the medical benefits section will cover the baby formula.
• Ask your health insurance company which prescriptions need a PA request in certain cases.
  Call your health insurance company by using the member services phone number on your health insurance card.
  
  Your doctor might need to send a PA request in certain cases, like if your child needs more medication or baby formula than your health insurance lets you pick up every month.
• Ask your pharmacist before you pick up your child’s medications.
  This way, the pharmacist can make sure your child’s doctor completed the PA request before you pick up any prescriptions. If the pharmacist sees that your child’s prescriptions need a PA request, they can send the prescription back to the doctor. Then, the doctor can send the PA request.

How can I make sure my health insurance company processes the PA request?

Call your health insurance company about 1 week (7 days) after the doctor has sent the PA request. Make sure you tell your child’s doctor if your health insurance changes. Depending on your health insurance, the doctor might need to send a new PA request.

If your PA request is denied, you can call the member services phone number on your health insurance card and ask about an appeals process. An appeals process is when you can try to get the PA request approved again. Work with your child’s doctor to see what other options you may have.

How will I know if my health insurance company has approved the PA request?

You can check with your pharmacist to see if your health insurance company has approved the PA request. If your health insurance has approved it, your child’s prescription medication or baby formula will be filled and paid for by your health insurance.

Who can I contact ar MGfC if I have more questions about PA requests?

If you have questions about PA requests, call our Boston or Waltham offices:

• Mass General for Children in Boston, Mass.: 617-726-8705
• Mass General West in Waltham, Mass.: 781-466-8967

Rev. 8/2015. Mass General for Children and Massachusetts General Hospital do not endorse any of the brands listed on this handout. This handout is intended to provide health information so that you can be better informed. It is not a substitute for medical advice and should not be used to treatment of any medical conditions.