There are some health care services your insurance covers only if you get approval before you receive care. This is called Prior Authorization. Your health care provider must contact your insurance company on your behalf to request approval for some procedures and services.
Prescription Prior Authorization works the same way for certain prescription medications and supplies. There are multiple reasons your insurance company might request prior authorization for certain prescription medications, including:
-Medications that may have potentially harmful side effects.
-Medications that can have unexpected side effects when combined with other medications.
-Medications you should only use for specific health conditions. -Medications that may be abused or misused which may also have a monthly limit on the quantity that may be covered.
-Medications that have less expensive non-equivalent alternatives.
Prior authorization allows us to assess the safety and appropriateness of these medications for your condition. The prior authorization review weighs the possible risks and harm against the potential benefits of taking the medication. We do this to give you valuable information when considering the next steps in your treatment. The ultimate goal of the prior authorization process is to help ensure you receive medications that are appropriate and safe for you. It helps protect you from medications that are inappropriate, not medically necessary, or overly expensive.
WPS publishes a list of medications that require prior authorization. This list also states who is responsible for completing the review, along with the phone and fax numbers for providers to use to complete the prior authorization requests. You can find the list by visiting our website. You can also see whether a drug requires prior authorization by reviewing the formulary documents posted on our website. Once a decision is made, you and your prescriber will receive a letter. It explains the prior authorization decision, if it is approved, and, if approved, it provides the approved dose and the date range authorized. It also may include special instructions for how or where to get your medication or supplies. If the request is denied, the letter will provide the reason for the denial. To ensure you can continue to receive your medication, we recommend that you contact your prescriber three to four weeks before the current prior authorization expires. This helps ensure there is sufficient time to complete a new authorization before the next prescription refill. A provider should contact the reviewer listed on the Drug Prior Authorization List for more information about what is required. We generally review and respond to standard requests within three to four days. You and your provider will receive a letter to notify you when a decision has been made. The time it takes to review your request can vary depending on the information that is sent to justify the requested medication. Sometimes, the reviewer will reach out and ask your provider for more information about the proposed medication. This can also extend the response time. For urgent, pre-service requests, our prior authorization reviewers will notify you and your provider, usually within 24-72 hours. For critical situations, your provider may request an urgent or expedited review which will be completed within 24 hours. WPS is here to help make health care easier for the customers we serve!
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