Does a doctor have to pre-authorize prescriptions with the insurance company?

Question

My doctor's office refuses to pre-authorize prescriptions with the insurance company. When I go to the pharmacy, the prescriptions then can't be filled. So I end up paying for the insurance coverage, the doctor's office visit copayment, but can't get the medication. Do I have any recourse other than to change my primary care physician? I've tried talking to the insurance company, but they say all I can do is file a complaint. Does the dept of banking and insurance have any jurisdiction over the doctor offices' non-compliance with the insurance company's contract?

Answer 1

First of all I want to correct some answers given. Doctors call insurance companies all the time to get what are called prior authorizations done for certain medications to be covered on patients insurance plans. The problem is that this process can take several days in which the patient is without medication. Secondly it is not the job of the pharmacy to find out what medication is covered by someone's insurance. The doctor is provided a list of covered medications and they just won't take time to look them up. The patient can call the toll-free number on their insurance card and ask them what medication is covered in certain classes such as ulcer medication, etc. Then let the doctor know what should be prescribed. Everything is not the responsibility of the pharmacy. The patient can do a little work to save themselves hundreds of dollars on some of their own prescriptions that are not covered.

Answer 2

1

Answer 3

Future Scripts Prior Authorization

Answer 4

You can request a different medication or see a different doctor. Your insurance company will not pay for the prescription unless it has PA from the doctor. I do not believe that your doctor is obligated to prior-authorize any medication. Other than that, I don't see any other way around it.

It is unfortunate that you had to pay for the visit and in addition pay full price for the medication. However, your doctor had no idea that your insurance company would request prior authorization when he wrote you the prescription. In the future, always know what is covered under your insurance plan so your doctor can prescribe a medication that will be covered under your insurance.

Answer 5

Not an answer but the drug I have been taking for 3 years needs pre auth. The drug in on the formulary as a Tier 2 generic. Problem is the dosage, It seems that the insurance co wants to second guess the doctor on the dosage, and the doc is fed up with the ins co.

Answer 6

some doctors will take the time to be aware of what meds are 'covered' under insurance and which are not

your doctor really does not seem to care, but I bet if you go back to the doctor's office they will be able to change the prescription to one that is covered

an alternative that i have done is order some meds in generic form from the online pharmacy site below, quite often these generics are cheaper than the insurance copays

bottom line, either push your current doctor to give you a perscription that is OK with your insurance company or find another doctor

Answer 7

It is no big deal to get a PA done on a medication that your prescription coverage won't cover without one. I work at at doctor's office and we do it all the time. If the office won't do it for you , go somewhere else that will.You pay alot for your health insurance.

Answer 8

I recommend one to visit this web page where you can compare quotes from different companies: http://INSURE-HELP.COM/index.html?src=5YArwfkwWA451

RE :Does a doctor have to pre-authorize prescriptions with the insurance company?
My doctor's office refuses to pre-authorize prescriptions with the insurance company. When I go to the pharmacy, the prescriptions then can't be filled. So I end up paying for the insurance coverage, the doctor's office visit copayment, but can't get the medication. Do I have any recourse other than to change my primary care physician? I've tried talking to the insurance company, but they say all I can do is file a complaint. Does the dept of banking and insurance have any jurisdiction over the doctor offices' non-compliance with the insurance company's contract?
Follow 23 answers

Answer 9

Get back on basics – burn more unhealthy calories than you ingest.

Answer 10

I just went through this last week, if the medication has to be pre-authorized (meaning it's not on teh insurances formulary list) it is your doctor's responsability to fill out the paperwork and get it to the Insurance company. My doctor filled out the paperwork sent it to insurance and i got my scripts paid for in 2 days. it's not that hard a receptionist can fill the paper and the doctor sign it, along with a copy of your insurance card. If they don't want to do it change offices and find a doctor that is helpful not hurtful to your pockets!