Medications Prior Authorizations

Prior Authorizations Resources

What is a prior authorization (PA)?

• According to Healthcare.gov, it is a decision by your health plan that a prescription drug is medically necessary. If approved, your pharmacy or pharmacy benefit manager will fill your prescription.
• It is only required if you are billing your prescription through insurance. You will not need prior authorization if you are paying out-of-pocket or if you do not have insurance coverage.
• This is a NOT a refill request, and you will simply need to call our office or your pharmacy should you need a refill.
• Click this link for an example of this.

What is a pharmacy benefit manager (PBM)?

• They are the companies that handle the prior authorization requests and/or dispense the medications on behalf of your health plan.
  • For example: certain Blue Cross Blue Shield plans have their pharmacy benefit manager set as CVS Caremark or Prime Therapeutics. Other insurance plans utilize other PBMs.
  • For further assistance, call your insurance plan to verify your pharmacy benefits.

What is health literacy?

• “It is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions,” according to Health.gov.

What is parental participation in patient’s care, and why is it so important?

• Think of this as parents behaving as caregivers by utilizing skills and health education discussed, instructed and approved by providers (ex. Doctors, nurses and health professionals).
  • Providers pass on health education so parents may engage and navigate the physical, psychological, emotional and social needs of patient.
    • This comes in the form of explaining expectations, assessing parental roles, and negotiating and encouraging the value of parental participation
• Benefits of parental participation? Here are some examples:
  • develops awareness and health literacy
  • enhances the quality of care, communication, and interaction between parent, patient, providers and insurance
  • assigns accountability for parental participation
  • encourages empowerment to fulfill your child’s health care needs so they can adopt beneficial physical and mental health-seeking behaviors for the future

How can you actively participate in your child’s medication prior authorization needs?

• Continue reading Prior Authorization Steps to find out!
• It is important you notify our office immediately if your Medicaid HMO plan changes monthly or suddenly. There is a strong possibility we will have to re-submit for a new prior authorization as Medicaid HMOs differ and not all prior authorizations transfer.
  • Example: If your insurance changes from Medicaid Molina to Medicaid Sunshine Health (or another Medicaid HMO, then we will need to obtain a new authorization.

Prior Authorization Steps

Before prior authorization submission:

Important: Please notify our office immediately if/when there is a change of insurance and PBM. This is especially important if your Medicaid HMO changes monthly. This will prompt us to re-submit prior authorization and remedy any delay that may arise.

Please identify the below steps (1-3) before requesting prior authorization. This will help our office provide the best patient care for your child’s medication needs

STEP ONE: Current insurance plan (Are you insured? If so, what is your insurance plan?)

• If you do not have Step 1, please enroll in an insurance plan before requesting prior authorization.
• If you are uninsured, for patient and financial assistance resources, please go to Financial Support

STEP TWO: Pharmacy benefit manager (PBM)

• If you are unable to locate Step 2, please call member services on the back of your insurance to verify pharmacy benefits.
• If you are unsure of this process, submit a prior authorization request by calling our office and we will initiate a benefits investigation process to obtain this information.
  • Please allow 1-3 business days for prior authorization submission
  • Depending on your insurance plan, it can take up to 1-15 business days for an outcome (based on standard and urgent requests)

STEP THREE: Complete consent form

• In the event we receive a denial for a prior authorization and determine an appeal is medically necessary, we will already have this on file with your completion of a consent form.
  • See list below and refer to your insurance plan’s consent form. Please use “Universal Consent form” if you do not see one listed for your plan.
    • FLBLUE_AppealConsentform
    • MedicaidUHC_AppealConsentform
    • Universal-Consent-Form-for-Denied-PA

After prior authorization submission and status:

• Approval: our office will notify parent/guardian/patient regarding details on how to proceed with obtaining medication and/or scheduling shipment. This will include the dispensing pharmacy phone number and the effective dates of the approval.
• Denial: our office will notify parent/guardian and proceed with further action. If you have a denial letter in your possession, please call our office immediately in the event we have not been made aware of this denial. Examples of handling denials are
  • 1) changing therapy (temporarily or permanently) to a preferred or alternative medication, or
  • 2) appealing to overturn denial. If Option 2 is selected, we will utilize your signed consent form to appeal on your behalf.
• Important: Consult with your doctor to choose the best medication(s), dose form, strength, and frequency for your child’s diagnosis. Ask them to inform you about how non-adherence to step-therapy or preferred medications may affect prior authorization approvals.

Patient Assistance: Specialty & Subcutaneous Medications

Pediatric Rheumatology

Pediatric Immunology

 Pediatric Allergy

Xolair

• About
• Uses & Risks

Additional Financial Support & Patient Assistance for Uninsured

Abbvie Patient Assistance Foundation

• About
• Patient Assistance Programs or call 1-800-222-6885
• Medications: Humira

Benlysta Gateway

Infusion Prior Authorizations

• If your child is to begin infusion therapy, please be advised that it is an extensive process. Depending on your insurance plan, it may take up to two weeks for insurance authorization approval. The infusion staff will contact you once a decision from your insurance has been made.
• If you have questions regarding coverage, co-pays, or bills received please contact your insurance company directly to discuss.
• If you have any additional questions, please ask the check-in staff to contact the clinic manager, Christee Glenn.