PDP "Prior Authorization"

[steve960]

After enduring years of significant cost increases with AARP /UHC PDP, I am inclined to change to an alternative carrier for a significant cost savings. Reviewing the formulary of the new carrier prior to switching reveals the need for “Prior Authorization” before filling a tier 3 prescription. While this is not unexpected having experienced initial rejection and eventual approval at AARP /UHC, I am concerned that the “Authorization” criteria is likely to vary between carriers regardless of any published consensus guidelines. Should the prescription not gain Authorization then the out-of-pocket expenses would dwarf the potential savings. I am curious whether others have experienced failed Authorization for a medication previously Authorized by a former carrier? Without access to my medical record and prescribing physician, is there any way to verify Authorization before making the carrier switch?

[steve960]

A follow up on my experience to provide closure and perhaps reassurance to others facing the same situation. I was able to refill the medication requiring Prior Authorization shortly before the end of the year in order to provide a short buffer while the new carrier reviewed my case. I also discussed my Authorization concerns with my treating physician ahead of the changeover who was prepared to submit the requested information as soon as my new carrier was active. As a result, the Prior Authorization was approved before I needed a refill of the tier 3 prescription. While every case is unique, I would suggest that others experiencing the same engage with their caregivers ahead of the carrier change, promptly submit the required medical information and attempt to secure enough of the medication ahead of time to last through the approval period.

[SereneSeagull]

I’ve had this come up before on meds that needed prior authorization.  Call the pharmacy ahead on given prescriptions, and compare the cost with and without insurance using a discount drug code company.  Some don’t need prior authorizations.

     The pharmacy in my grocery store does not need prior authorization for a drug that my prescription drug plan did .  So I found out I could use a discount drug code plan instead of my insurance. So not only did I not need a prior authorization for the med on my prescription my doc wrote, I was able to use one of those discount drug codes (one called Hippo of all things), like GoodRx or SingleCare, etc…Pharmacy plugged all that in and boom, savings and no prior authorization.  Sometimes not using a carrier is cheaper and hassle free in some instances, but a little leg work in trying to get it done is needed, unfortunately.  Cost comparison and talking to pharmacy helped me on this, rather than insurance company.  
   
Edited to add:  Doesn’t work for all meds though.

[somarco]

Prior authorization is only needed when using a drug plan . . .  not needed when paying cash. . . the Part D prior authorization may be required by your drug plan. If so, the Rx cannot be filled until your doctor contacts the drug plan carrier to authorize approval. Each Part D carrier has their own form which needs to be completed by your provider. 

Drug discount plans can be used with some generic drugs, not brand names.

[SereneSeagull]

Thank you, I was not using part D in my situation.  

[GailL1]

@somarco 

Welcome back - glad you are here cause I’m pretty much done.  Too old and have other stuff to do before I really move on - 

[somarco]

Not really back . . . just popped in after getting a kudo notice from a post 5 years ago. I have enough going on without monitoring this board like I once did. You are a good friend and this board won't be the same without you. Best to you!

[GailL1]

I will still pop in from time to time - got to keep this WILD group under control, ya know.

’Tis the Season and all that - Have A Great One. 

[CBtoo]

The problem with doing that (using a coupon and not your D) is then it doesn't count towards your maximum out of pocket. It used to be you could then submit proof of payment so it counted but it looks like this is no longer true in 2026. At least not in my state.