Prior authorization for folks with insurance

When you first start hormones, when your insurance information changes, or when route or dose of medications change, your insurance may require prior authorization. Prior authorization is the process of determining whether an insurance company will cover your medication. The process works as follows: PPMI sends your prescription to your pharmacy; typically your pharmacy will then contact PPMI to let us know if a prior authorization is needed; our PPMI team will then initiate and complete a prior authorization submission to your insurance company. A determination of coverage by the insurance company may take seven business days (or more if a denial is encountered or additional information is requested). If your prescription requires a prior authorization and you have not heard back about a determination a week after the prescription was sent, please contact us via the portal for an update.

Prior Authorization 101

Not all medications require prior authorization but here's what happens when it is needed.

What is a Prior Authorization (PA)? This is a word used by insurance plans when a medical treatment requires more info from a medical provider before it pays any covered expenses. When you first start hormones, when your insurance information changes, or when a medication dose or route changes, your insurance may require prior authorization.

Step 1: PPMI visit

After your visit, PPMI sends your prescription to the pharmacy.

Tip: Call ahead to the pharmacy before picking up your medication.

Step 2: Pharmacy

If a PA is needed, typically your pharmacy will contact PPMI by submitting a request. This may delay picking up your medications.

Step 3: Insurance approval

Insurance approves or denies coverage. Denial letters must be shared with PPMI and the patient with reasons for denial, who may appeal, and how.

If we receive a denial, we will review your options and notify you of the next steps (to appeal, if applicable), alternative covered drugs, or ways to pay and save money without coverage.

Step 4: Pharmacy contacts PPMI

PPMI receives a form from your insurance plan asking for more info about the prescription. This is normal, and we have a team in place to complete and return the form. A determination of coverage may take seven business days (or more if a denial is encounter or additional info is requested).

Step 5: Pharmacy fills prescription or PPMI appeals

If your plan approves the PA, the pharmacy fills your prescription. PPMI may or may not know if this happens.

If the pharmacy has told you a PA is needed or pending still after one week, reach out to your PPMI care team for help.

What else should I know?

You can contact your plan anytime to ask if a specific treatment is covered, requires a PA, the cost you may have to pay, if you have to "try and fail" any other treatment(s) first, and if so which ones. "Trying and failing" means completing a covered treatment or medication long enough for your medical provider to report why it doesn't work for you; insurance plans call this "step therapy."

Will I need a prior authorization to cover my medication?

Every plan has its own formulary (catalog of medications) it will cover. The insurance formulary also specifies if a prior authorization will be needed. Not all medications require a prior authorization for approval but some do. We have a team of navigators that can help you if prior authorization is required.

Prior authorizations are only needed when you wish to use insurance to cover a medication, which can lower out of pocket fees, like copays.

Do I need to worry about prior authorizations if I will not be using insurance?

No, you will not need a prior authorization if you are not using insurance coverage to obtain your medication. If you already have a prescription from a medical provider ready for pick up at the pharmacy, you can tell the pharmacist that you don’t want to use insurance (even the pharmacy has one on file). Please be aware that some medications may be more expensive when you don’t use insurance, and a drug discount coupon from GoodRx can be used to lower the price.

What if I have more than one active insurance plan or recently switched?

If you have recently switched plans, make sure your pharmacy has the correct one on record for you.

If you have more than one insurance plan, your pharmacy will usually try to bill your primary plan first before using a secondary plan. If you have multiple active insurance plans, we ask that you ask your pharmacy which plan was billed for your prescription; once you get this information from the pharmacy, please send us a portal message to let us know. This will help us reach out to the correct insurance company plan faster and more easily if prior authorization is required.

Tip: If you have a Medicaid plan and another active plan, the Medicaid plan will be your secondary plan most of the time because it’s a payer of last resort, meaning that if you have another plan that can be used for coverage, it has to be used first.

How will I know if I need a prior authorization?

You can either check with your insurance company ahead of your visit to confirm which forms of gender affirming hormone therapy medications they cover and if any of those require a prior authorization or you can wait until the pharmacy receives the prescription to initiate a prior authorization request to PPMI. PPMI recommends calling your pharmacy prior to picking up medication to confirm the status of your prescriptions prior to trying to pick up your medication. By calling, you might find out that your prescriptions have been filled without issue or that there will be a delay due to prior authorization.

Can PPMI tell me during my visit if I will need to wait for a prior authorization before calling my pharmacy?

No. Unfortunately, we cannot be certain whether a prior authorization will be needed when we send your prescription. Each insurance plan has its drug formulary (a catalog) of which medications they may or may not cover and insurances have different criteria that must be met for coverage.