What is a prior authorization and do I need it to get my medication?

If you’ve been denied coverage on a specific medication or treatment by your insurance company, we can issue a prior authorization asking them to reconsider—and we are often successful.

If your insurance denies coverage of a certain treatment or medication, one of the best options you have to move forward is obtaining a prior authorization. A prior authorization asks your insurance company to reconsider covering the medication or treatment based on its medical necessity.

How does prior authorization work at Potomac?

While we cannot guarantee a positive outcome, submitting prior authorization greatly increases your chance of obtaining coverage for a treatment or medication. Here’s how the process works:

  •   If you are denied coverage, Potomac staff will receive a fax notifying us, at which point we will get in contact with you about obtaining a prior authorization.
  •   If you choose to move forward with prior authorization, your doctor will gather and send additional information to your insurance company explaining why it is medically necessary for you to be prescribed a particular medication.
  •   Once submitted, Potomac staff will receive notice of approval or denial for prior authorization within one week. Typically they arrive within two to three business days, and sometimes we even get same-day approval.
  •   If prior authorization is denied, you can ask our team to submit an appeal. This can take up to a few weeks, but often achieve a positive result.

Does prior authorization cost anything?

Because Potomac is a private pay practice, your treating doctor may charge a small fee for your prior authorization. The reason we do so is because authorization is frequently a lengthy process and may require your doctor to complete multiple phone calls to your pharmacy and insurance company and to gather and submit correct documentation. The appeal process may also incur a fee for similar reasons.

If you would rather not pay this fee, you can pay directly out of pocket, or you can look for a discount or coupon card such as GoodRX or directly from the manufacturer of the medication. If you have any other questions about prior authorizations or appeals, please don’t hesitate to give us a call at (301) 984-9791.