Winning The “Prior Authorization” Medication Game

By Dr. Alex Dimitriu, Mar 17, 2022

Top tips for consumers about managing medication costs

• Consider generic medication if possible to lower costs
• Check on GoodRx.com to find the best prices and pharmacies for meds
• When a generic request is denied due to prior authorization, ask about the cash price
• Pay cash over using insurance when the cost of the medicine is low to speed things up

I work as a physician. When I put my patient on a new medication which they need to start, the sooner the better. I also have existing patients who need refills of medications they are on, which are generic, and I try to order a refill. Often, the pharmacy tells my patient they cannot have their medicine, because “your doctor needs to speak with your insurance company.” The patient is sent away and left in a land of limbo, sometimes in urgent need of a refill which now has been denied.

What’s going on here? Well, enough that I thought it was time to write a brief guide for my own patients and all other patients who are denied medications that they need. In medicine, there are generic medications and there are name brand medications. Name brand medications tend to be new, still protected by a patent, and expensive. Generic medications are off patent, made by several manufacturers, and much less expensive. For example, Zoloft (r) is the name brand version of sertraline, a commonly used anti-depressant. The name brand Zoloft (r) is still expensive, but the generic is exponentially cheaper. I use generic medications whenever available, without any loss in benefit in comparison to the name brand meds and at a much lower cost to my patients.

Whenever possible, I advise my patients to give the generic medicine a try. When there is no generic version available, it’s important to let patients know it will be costly. If they pursue insurance for the medicine, I do expect a request for a prior authorization, and both the patient and I know this can take a few days.

But what happens when I prescribe a generic and the request is denied pending prior authorization? The unfortunate reality is that some pharmacies are charging a higher marked up price for the medicine and telling the patient they have to use insurance to get it. Using insurance to pay the higher price requires a prior authorization, the medicine is delayed, and the patient (and the doctor) are left frustrated. This feels unfair to me when the cash price for most generics is often quite low. See for yourself at my favorite prescription site, GoodRx.com.

Indeed, many prescription medications are available for a very low cost (even better using coupons on GoodRx.com), and do not require prior authorization when paying cash, outside of insurance.  Always ask your doctor and pharmacist if there is a generic version of the medications you are taking. More importantly, check online to see the best cash price for your medicines, and learn which pharmacy to find it.

At the pharmacy, always ask what the cash price would be. Then check against GoodRx.com.

Cost is not my main point here. The bigger issue is that patients are often denied medicines that they need in a timely fashion, while pharmacies try to charge the insurance company more for inexpensive medicines. This starts prior authorizations even when they are not needed. Patients then do not get the medications they need in time, and this, is not good for anyone.