Insurance companies use benefit management strategies like prior authorization and step therapy to check whether a prescribed treatment is medically necessary. Ideally, your insurance company uses those strategies to learn more about your health condition and understand why you need a specific treatment before deciding to pay for it.
Each insurance company has unique processes for prior authorization and step therapy, so check with your plan to find out if you need approval before it covers a particular treatment.
Prior authorization
Prior authorization means your insurance company must review and approve a particular medical service, test or treatment before agreeing to cover it. Prior authorization requirements vary from plan to plan. Generally, you’ll need reauthorization at least once a year for pulmonary hypertension medication. In most cases, your PH care team will handle the prior authorization process for you.
Step therapy
Step therapy means the insurance company requires you to try other medications or treatments before it agrees to cover therapy your physician prescribes.
Step therapy can delay access to effective PH treatment because the approved treatment might not work as well as the medication your doctor prescribed. However, you can appeal step therapy requirements to start your prescribed therapy as soon as possible.
Requesting prior authorization
Prior authorization requirements can feel unnecessary and aggravating. If you need to request prior authorization yourself, call your insurance company to ask about its process.
Start by asking the name of each insurance representative you speak with and write down what they tell you. Make sure you ask these questions:
- Does my plan require prior authorization to cover this medication or treatment?
- How do I get prior authorization? Who must make the prior authorization request? Physician, patient or nurse?
- What email address, fax and/or phone number should I use to make and follow up on my request?
- What documentation do I need, such as paperwork or proof or medical necessity?
- How long will it take to make a decision? If they say they aren’t sure, ask how long it usually takes.
- If I receive prior authorization, how long is it approved for? When do I need to reapply?
- How will I find out whether you have approved my request?
Some programs require your doctor to call or send a letter of medical necessity, a document explaining why the treatment or service is appropriate for diagnosing or treating your medical condition. Including a letter from your physician can be helpful, even if your insurance company doesn’t require it.
Following up
Follow up phone conversations in writing.
Keep your correspondence simple and to the point. Include relevant dates, names of representatives with whom you spoke and their message to you. Include your name, policy number and other identifying information.
Carefully follow the steps outlined by your health plan. Otherwise, your request could be delayed or denied.
Need help getting your PH treatments covered?
Ask your care team to help manage your insurance issues. Health care professionals often are familiar with securing prior authorization, appealing step therapy policies and navigating the appeals process if the insurance company denies your claims.
