The Prior Authorization Process in Pharmacy

When Is Prior Authorization Required?

Prior authorization (PA) is a requirement from insurance companies that the prescriber must obtain approval before certain medications are covered. Common PA triggers include non-formulary medications, brand-name drugs when generics are available, specialty medications, and medications exceeding quantity limits.

When a pharmacy receives a PA rejection, the claim will not process until authorization is obtained. The pharmacy technician plays a key role in identifying PA rejections and communicating between the prescriber and insurance company.

The PA Workflow

The typical PA process involves: identifying the PA rejection, notifying the pharmacist, contacting the prescriber's office with required forms, and following up on the status. Many PBMs now offer electronic PA (ePA) systems that speed up the process.

PA requests typically require clinical documentation including the patient's diagnosis, previous medications tried, and reasons why the requested medication is necessary. Turnaround time varies from hours to several days.

Exam Tips

Understanding the PA process demonstrates operational knowledge valued on the PTCB exam. Practice with our PTCB flashcards and mini exams.