What is Prior Authorization?

A FlexScripts Fact Sheet

A Prior Authorization (PA) program is a cost-savings piece of your prescription drug benefit. It makes sure that you get the appropriate medication by preventing improper prescribing of drugs that may not be the best choice for your health condition.

What Does This Mean?

When your pharmacist tells you that your prescription needs a Prior Authorization, it simply means that they need more information to see if your plan can cover the drug. Only your doctor can provide this information and request a Prior Authorization.

How Does it Work?

Here’s one scenario: A particular type of medicine is very good at treating a serious skin condition, but may have some especially nasty side effects. As luck would have it, the drug is also good at reducing wrinkles. A health plan with a PA program will cover the drug if a doctor prescribes it for the medical condition, but not if it’s done for cosmetic purposes—unless the doctor can prove that it is the best drug for the job.

This way the patient is protected from those side effects, and the plan saves money by not paying for an expensive medication that’s not really appropriate for the condition.

Can I Appeal if My Medication is Not Approved?

Yes. Your doctor’s office can appeal the decision. FlexScripts Administrators may request additional information. Your appeal will be reviewed by our clinical staff, and their decision will be communicated in writing to the your doctor within 10 business days from the receipt of all information.

How Does FlexScripts Handle PAs?

When a member receives a prescription medication that requires a prior authorization:

  1. The Pharmacy receives a message to contact FlexScripts Administrators. The pharmacy either calls to start the process, or contacts the doctor’s office to notify them that a PA is needed.
  2. FlexScripts Administrators gathers all the necessary information and faxes the PA form to the doctor.
  3. The doctor is instructed to provide a list of all other drugs previously tried with start and end dates, a reason for discontinuing them, a patient diagnosis, and the doctor’s signature.
  4. The PA form goes to FlexScripts clinical review. The turnaround time for review is generally within 1 to 2 business days, or sooner.

When the review is complete:

  • If the PA is approved: The pharmacy is contacted to run the claim again, and will contact you when the prescription is ready.
  • If the PA is not approved: Physician’s office is notified.