Prior Authorization Process

Why does my insurance company require a prior authorization?

Health insurance companies require a “review” of some medical treatments to determine if it is “necessary” for your care. This is usually an attempt by your insurance company to control costs. This is a time-consuming, convoluted and frustrating process, but what is currently required by insurance companies in order to provide you with the treatment you deserve.

Do all insurances require a prior authorization? Does it matter if I have Commercial or Federal insurance?

Yes. All insurances require prior authorization for these types of medical treatments. Whether you have Commercial insurance (such as BCBS, UHC, Aetna) versus a Federal insurance (such as Medicare, Medicare Advantage, or Tricare) determines what types of financial assistance may be available to you if you have a high copay or the medication is denied.

Who is Responsible for Following Up with the Prior Authorization ?

The prior authorization is the patient’s responsibility, as this is required by the insurance of the patient’s choosing. However, we acknowledge this process is absurdly complicated and frustrating, and therefore our office is happy to have assists with navigating the approval process.

Am I charged for this authorization?

Any paperwork required by your insurance for the medication authorization will be completed in-office and your insurance will be billed appropriately for this time. A copay, deductible &/or coinsurance may apply. A fee of 35$ applies to any paperwork completed without an in-office visit. Otherwise, patients are welcome to visit the medication website to self complete the medication authorization process.

How does the prior auth process work at Vital Dermatology?

1) In-office Visit to Begin the Authorization Process: *All authorizations AND reauthorizations require an in-office visit to complete the following:

  • Application(s): Medication and patient assistance application(s) are completed/signed by both the patient and Dr. Beasley.

  • Consent: To authorize our office to submit the prior auth on the patient’s behalf.

  • Laboratory testing (if applicable): If your medication requires laboratory results to begin/continue treatment, the prior auth process is ON HOLD until your lab results are reviewed, so completing your labs as soon as possible will expedite this process. If you completed labs but have not heard from our office within 7 business days, please call/message our office to ensure the results were received.

  • Authorization submitted: Your application(s), clinical notes, ID, insurance card(s), and prescription are submitted to Tandem Pharmacy

2) Tandem Pharmacy will be contacting you via text &/or call to complete the required insurance paperwork & collect electronic signatures.

  • Who is Tandem? A free 3rd party company that automates your insurance approval process in order to obtain faster medication access, on-call support, and coupons/financial assistance to save the patient medication cost.

  • For more information, visit www.tndmrx.com.

3) Insurance decision: Typically, within 2 weeks your insurance company will declare a decision. The insurance company will determine one of the following outcomes for your medication:

  • Approved: Approval dates range from 6 months to 2 years and then re-authorization may be required.

    • Approved but co-pay too high (both commercial and Medicare/Tricare): Co-pay cards and patient financial assistance may be available to reduce your cost. See the links below for more information.

  • Denied

    • Appeal or change to an alternative treatment: Appealing your insurance’s decision is often futile. Unless medically necessary, Dr. Beasley will select a similar medication for that that is preferred by your insurance, and the prior authorization process is restarted with your insurance.

    • Receive 1-2 years of free medication through a sponsored program (commercial insurance ONLY)

    • Submit for patient assistance (both commercial and Medicare/Tricare): Some medication companies offer free or low-cost drug coverage if your household income is below a certain limit. See the links below for more information.

4) Medication Delivery to Home: *You must personally verify the shipment date with the pharmacy or your medication will not be received. Please answer/return any incoming calls regarding medication delivery.

  • What is a Mandated Pharmacy?: Each insurance mandates that a specific pharmacy dispenses your medication. Once your insurance has approved your medication, it will be transferred to your Mandated Pharmacy. You will be contacted by this pharmacy to confirm your delivery date. Examples: CVS Caremark, ExpressScripts, Accredo, AllianceRx, OptumRx.

5) Injection training (for injectable medications): You may schedule injection training at Vital Dermatology or visit the medication links below for virtual injection training.

6) Follow-up: Follow up is required every 6-12 months for these medications in order to ensure the medication is effective, without side effects, to order/review lab results and to complete insurance reauthorizations

How Will I Be Updated About My Prior Auth Status?

  • Text message & phone calls updates are sent by Tandem & our office in order to to notify of the following: approvals, denials, copay support, patient assistance approvals, and the pharmacy number to call for medication delivery.

  • Contact TANDEM (ph: 833-473-5013) for updates regarding your authorization status.

Summary of Patient Responsibilities:

  • Pay attention to incoming text messages &/or calls from TANDEM (ph: 833-463-5013)

  • Complete all requested electronic signatures for your insurance paperwork from TANDEM.

  • Visit the medication website to familiarize yourself with injection training and support programs for copay and financial assistance.

  • If your medication is approved, you MUST ANSWER THE PHONE OR CALL THE MANDATED PHARMACY to schedule delivery of your medication.

  • Follow-up visits (for all) and up-to-date lab studies (if applicable) are required for reauthorizations.

  • Notify our office of any changes in your health insurance coverage.

LINKS

*See links below for information on medication side effects, dosing, injection training, nursing support, copay discount cards and additional financial assistance programs.

CIBINQO (pill, labs required)
Patient Support Program (Pfizer Dermatology Patient Access)

COSENTYX (injection, labs required)
Patient Support Program (Cosentyx Connect)
Injection Training

DUPIXENT (injection, no labs)
Patient Support Program (Dupixent My Way)
Injection Training

OTEZLA (pill, labs required for select patients)
Patient Support Program (Amgen Support Plus)

RINVOQ (pill, labs required)
Patient Support Program (Rinvoq Complete)

SKYRIZI (injection, labs required)
Patient Support Program (Skyrizi Complete)
Injection Training

TALTZ (injection, labs required)
Patient Support Program (Taltz Together)
Injection Training

TREMFYA (injection, labs required)
Patient Support Program (Tremfya With Me)
Injection Training

For more information on this frustrating process and how your insurance requirement of prior authorizations may negatively affect your care, see WHAT DOCTORS WISH PATIENTS KNEW ABOUT PRIOR AUTHORIZATIONS