The Why Behind Prior Authorizations

When a member goes to a pharmacy or needs a specific procedure or test, they may be told they need prior authorization before insurance will cover it. A prior authorization (PA) is required when your doctor determines you need certain services, such as specific procedures, tests, medications, or durable medical equipment and are based on nationally recognized care standards. Your doctor will get approval from your health insurance plan before this service is provided to you. A few examples of services that require prior authorization are skilled nursing care, CT and MRI scans, radiation therapy, certain genetic tests, and some Medicare Part B and D drugs.

Why are Prior Authorizations Required?

Prior authorizations are required for various reasons. They are not just a hindrance and a barrier to you receiving care.  Below are a few of the top reasons they are required:

• Medical Necessity: to determine if the treatment, service, or drug is recommended for your specific situation and to check to make sure services aren’t being duplicated.
• Cost: to determine if the treatment, service, or drug is the most economical treatment option for your specific condition or situation.
• Safety: to determine and minimize drug interactions or therapies that can lead to harm, misuse, or potential abuse. 

What are some specific procedures, tests, medications, or durable medical equipment that may require Prior Authorization?

Your Evidence of Coverage Booklet and the Drug Formulary are where you can find the specific tests or medications that require prior authorization, however below are a few common items that may require prior authorization:

• Acupuncture for chronic low back pain
• Home Infusion Therapy
• Durable medical equipment: IV infusion pumps and oxygen equipment
• Diagnostic Radiology Services, i.e. CAT scans, MRIs, PET CT Scans
• Drugs used with an item of durable medical equipment (DME)

What is the process to obtain a Prior Authorization?

Your Provider or Pharmacy will work with BayCarePlus to determine if the procedure, test, or medication is medically necessary. This usually requires communication between BayCarePlus and your provider to discuss your treatment history and your condition. BayCarePlus will notify you or your provider once they have approved or denied the request. Prior authorization can take days to process, and it depends on what procedure or medication your provider is prescribing and the response time between the communications with your provider.

How are Prior Authorizations Helpful?

Prior authorizations are helpful because they ensure that the ongoing or recurrent treatment, service, or drug is actually helping your specific condition. Prior authorizations also verify that certain medications, treatments, or tests aren’t being duplicated if patients see multiple providers or specialists. They also prevent the misuse or overuse of medications that may have the ability to be abused. 

The primary benefits of prior authorizations are to ensure safety, optimize patient outcomes, as well as responsibly monitor costs to the patient and the health care system as a whole. Covered services that need prior authorization are marked in the Benefits Chart of your Evidence of Coverage booklet (EOC) and covered drugs that need prior authorization are marked in the Drug Formulary.