Prior Authorization

When your health insurance plan requires approval for certain medical services or treatments before the services or treatments are rendered, this is called prior authorization. Prior authorization requirements will vary from plan to plan.

Step Therapy

Step therapy is a requirement that less costly and risky treatment alternatives be explored and deemed unsuitable before more uncertain or expensive therapies are approved. Step therapy may impact patients with pulmonary hypertension (PH) if it slows access to the specific therapy recommended by a PH specialist.

Navigating Benefits Management

Insurance companies use benefit management strategies such a prior authorization and step therapy as a way to ensure that the prescribed treatment is medically necessary. In other words, the insurance company does not want to pay for a product or service that is not really needed.

Through prior authorization and step therapy, your insurance company can learn more about your health condition and why the treatment is needed before it decides whether to cover or pay for it.

Because each insurance company has a unique prior authorization process and step therapy process, the only way to know if your insurance company requires approval for a particular treatment beforehand is to be proactive. Many step therapy requirements can be appealed so you can get the treatment your doctor prescribed right away.

Obtaining Prior Authorization

Obtaining a prior authorization can seem like an unnecessary and aggravating reality when it comes to accessing your treatment. Often, your PH medical team will take care of this process for you behind the scenes. If you need to request prior authorization yourself, there are some steps you can take to streamline the process. If you suspect or know that you will need to get your medical services or treatment approved before you can receive them, act now:

  • Call your insurance company and ask questions about the process.
    Because each insurance company has unique prior authorization and step therapy processes, the only way to know if your insurance company requires approval is to ask. Here are questions to consider asking your insurance company about its process.

    • Does my plan require prior authorization for coverage of this particular service or product? For example, does my plan require prior authorization for an infusion pump? Do I have to get prior approval for my bosentan prescription?
    • How do I get something prior authorized? What is the process? Who must make the prior authorization request – physician, patient, nurse?
    • What is the email address, fax number and/or phone number I should use to make and follow up on my request?
    • What documentation should be included? Be sure to ask what paperwork or proof they will need.
    • How long will it take for a decision to be made? If they say they are “not sure,” ask, “How long does it usually take?”
    • If prior authorization is given, how long is it approved for or when will the approval time “expire?”
    • How will I find out if it has been approved or not?
  • Make your medical providers aware and seek their assistance.
    The decision to cover a treatment is based on information that your doctor or nurse sends the insurance company. For some programs, your doctor may have to call or send a special letter called a “Statement of Medical Necessity” or “Letter of Medical Necessity” that justifies the service rendered as reasonable and appropriate for the diagnosis or treatment of a medical condition or illness. It is often helpful to include a letter of medical necessity from your physician to your insurance company, even if your company does not require it. View a sample letter of medical necessity.
  • Follow up in writing after speaking with a health plan representative on the phone.
    Keep your correspondence simple and to the point. Include relevant dates, names of representatives with whom you spoke and their message to you. Also be sure to include your name, policy number and any other identifying information.
  • Carefully follow the steps outlined by your health plan. Otherwise, your request could be delayed or even denied.