Prior authorization
Prior authorization help that follows through
When your plan rejects a prescription, we find out exactly what it needs, share it with your prescriber’s office, and follow the request until there’s a decision.
The basics
What a prior authorization is
A prior authorization is your health plan’s requirement to approve certain medications before it pays for them. Plans also use step therapy and quantity limits. These rules are common for dermatology topicals, biologics, migraine preventives, GLP-1 medications and many brand-name drugs.
We never alter clinical information, sign for a prescriber, or promise an approval. Coverage decisions belong to your health plan.
Common reasons
Why a claim gets rejected
Prior authorization required
The plan wants documentation from your prescriber first.
Step therapy
The plan wants proof that a lower-cost option was tried.
Quantity limit
The prescribed amount is more than the plan allows without an exception.
Not on formulary
The drug isn’t on the plan’s covered list, so an exception is needed.
Refill too soon
The plan thinks you still have supply. We can request an override when appropriate, such as after a dose change.
How it works
How the process works
We read the rejection
We find out why the plan didn’t pay: a prior authorization, step therapy, a quantity limit or a drug that isn’t on the formulary.
We send the plan’s criteria
Your prescriber decides whether to submit a request and provides the clinical information the plan asks for.
We follow it through
We check the status with your plan and keep you updated until there’s a decision.
We fill and deliver
Once it’s approved, we fill your prescription and deliver it, or have it ready for pickup in Hicksville.
Roles
What we do, and what only your prescriber can do
| Statmeds can | Your prescriber provides |
|---|---|
| Identify the exact requirement from the claim rejection | Diagnosis and clinical documentation |
| Share the plan’s criteria and request format with the office | The decision to submit, and any medical-necessity statement |
| Share covered alternatives the plan lists | Any decision to change your medication |
| Check status with your plan and update you | Peer-to-peer reviews and formal appeals |
| Fill and deliver once it’s approved | A new prescription when therapy changes |
Medicare
If you have Medicare drug coverage
You have the right to ask your Medicare drug plan for a coverage determination if you disagree with information from the pharmacy, and to ask for an exception if:
- you need a drug that isn’t on your plan’s formulary,
- a coverage rule, such as prior authorization or a quantity limit, shouldn’t apply to you for medical reasons, or
- you need a non-preferred drug and want the plan to cover it at the preferred price.
How to ask your plan for a decision
You or your prescriber can contact your plan using the number on your member card. If waiting up to 72 hours could seriously harm your health, ask for an expedited (24-hour) decision. For an exception, your prescriber must send the plan a supporting statement. You can also call 1-800-MEDICARE.
Medicare rights notice (PDF)Questions
Prior authorization questions
Can’t find your answer? Call (516) 900-0636 and a team member will help.
How long does a prior authorization take?
It depends on your plan and how quickly your prescriber’s office responds. Many standard requests are decided within a few business days. Medicare drug plans generally must decide standard requests within 72 hours and expedited requests within 24 hours once they have your prescriber’s supporting statement.
Will you change my medication to something covered?
Not on our own. We can share covered alternatives, but only your prescriber can change your therapy. New York law generally requires us to substitute a less expensive, FDA-rated equivalent generic unless your prescriber indicates “dispense as written.” We’ll tell you when we substitute.
What if the prior authorization is denied?
We’ll explain the denial, the appeal options your prescriber can use, any covered alternatives and the cash price, so you can decide with your doctor.
Is there a fee for prior authorization help?
No. There’s no separate fee for coordinating a prior authorization on a prescription we fill.
Claim rejected somewhere else?
Transfer the prescription to us and we’ll take it from there.