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Get Faster Pharmacy Authorizations
Insurance companies often require pharmacy authorizations for medications that:
- Have serious side effects or pose risks when combined with other drugs
- Are prescribed to treat specific conditions (e.g., Medicare Part D) or are often misused
- Treat non-life-threatening medical conditions when lower-cost formulary medications are available
- Are subject to step therapy (i.e., when patients must try lower-cost alternatives first)
These approvals often require extensive documentation and repeated follow-ups with insurers, leading to unnecessary delays in patient care. That’s where we come in. Our insurance verification specialists have the experience and skill to secure approvals faster, prevent treatment delays, reduce claim denials, and ensure smooth patient scheduling.
Speed Up Approvals for High-Value Claims
Our team speeds up the approval process for high-value claims with efficient pharmacy prior authorizations and proactive follow-ups that keep reimbursements on track. By verifying pharmacy benefits in advance, we help providers and plan members understand coverage clearly — before the patient visit. Our team of experts:
- Handles prior authorization requests for all healthcare specialties
- Works with both government and private insurance plans
- Confirms drug coverage, copays, deductibles, and other plan details upfront
- Prepares and submits documentation that meets payer criteria and medical necessity standards
- Secures faster approvals for high-value claims — improving care delivery and boosting your cash flow
Save Time and Focus on Your Patients
Our support streamlines your prior authorization process and minimizes delays. Our team keeps things on track, so you can focus your time and resources where they matter most — on patient care, not on paperwork or appeals.
Why Outsource Prior Authorizations to OSI?
Real-Time Verification
In addition to checking payer portals, our team directly calls insurance companies to confirm drug coverage. This speeds up approvals and ensures timely treatment for patients.
Clear Communication
Our specialists maintain strong relationships with payer representatives, offering quick clarifications when needed and helping you navigate the process smoothly.
Expert Knowledge
Our team is well-versed in the pre-authorization policies of both commercial and government payers. We help ensure your requests are complete, accurate, and in line with payer requirements.
We serve all 50 states
Our Pharmacy Prior Authorization Process
Our team ensures that every request is tracked and monitored closely until approval is granted. We follow up with payers regularly and keep you informed of any additional requirements. If a request is denied, we provide comprehensive appeal support to strengthen your case for approval.
Identify Medication Needing Prior Approval
We start by identifying which prescribed medications require pre authorization based on the patient’s insurance plan.
Gather Required Documentation
We collect all relevant clinical notes, test results, and other supporting materials to demonstrate medical necessity. This includes the patient’s diagnosis, treatment history, and justification for the prescribed medication.
Evaluate Payer-Specific Requirements
Our team reviews the payer’s coding, documentation, and authorization request form requirements to ensure everything is in compliance.
Prepare the Authorization Request
We assist in accurately completing the authorization request form and attaching all necessary clinical documentation.
Submit to the Payer
Once everything is in order, we submit the completed request electronically. The payer then reviews it to ensure it meets their coverage guidelines.
Track & Follow Up
Monitor the status of each request, follow up with payers, and provide updates until approval is received.
Benefits of Partnering with OSI
Dedicated Team: Consistent support from experienced specialists
Quality Checks: Multi-level review reduces errors
Proactive Monitoring: Keep approvals on schedule
Timely Reporting: Receive updates that fit your workflow
Cost Savings: Reduce administrative overhead by 30–40%
HIPAA Compliant: All processes meet strict patient privacy standards
How Our Insurance Verification and Prior Authorization Services are Priced
Reduce administrative hassles and welcome efficiency with our skilled team supporting you. Choose from our flexible pricing plans based on your needs.
Full-Time Equivalent
In this model, services are billed based on the equivalent cost of a full-time employee (FTE) for a specified duration, usually monthly or annually.
Per Verification Billing
Like an FTE model, a person is dedicated to your practice. Perfect for a practice that is busy. They work as an extension to your business.
FTE/Per Verification Billing
This option is ideal for a practice that is unsure about their work requirements. This can have per request pricing for eligibility and other functions.
AR is only FTE
In this model, you will be charged a fixed monthly or annual fee based on the number of full-time equivalent staff required to manage your practice’s AR follow-up activities.
FAQs
What is pharmacy prior authorization?
Pre-authorization is a process that involves obtaining an approval for a prescribed device, procedure, service, or medication from health plans before it is administered as designed. This preapproval step ensures that prescribed drugs or treatments meet plan criteria for coverage. Insurers allow usage of appropriate medications only after thorough consideration of the patient’s health outcome and value to the plan sponsor. Services that require plan approval are reviewed before payment and finalized only when all conditions are met.
What information is typically required for a pharmacy authorization request?
Common requirements include the patient’s diagnosis, treatment history, the specific medication being prescribed, dosage, and duration of therapy. Supporting clinical documentation may also be needed.
How long does the approval process generally take?
Response times vary by health plan. Expedited reviews may take 24–72 hours, while standard approvals can take up to 14 days, depending on payer policies and the type of medication.
How do you handle pre-authorization denials?
When a request is denied, both you and your patient can appeal the decision. Our team can guide you through the appeals process and help you overturn the denial.
Why do health insurance companies require pharmacy prior approval?
Health insurance companies use a PA as a means to essentially put a restriction in place to reduce unnecessary prescription drug use and cost of the service. Prescribed medications are approved after verifying the medical necessity to ensure it is the most economical option viable for the health condition. If a less expensive but equally clinical effective alternate is available after review, then the cost-friendly option is recommended by payers. It is an evidence-based process that minimizes overall medical costs to improve affordable healthcare access for patients. For example, if the physician prescribes an expensive drug, the insurance company may authorize it only if the physician can show that it is a better option than a less expensive medication for the condition.
What types of drugs require PA?
Each insurance company has a team of physicians, pharmacists and other medical specialists who review and research to create the list of newly approved medicines and existing medicines. They also consult medical practitioners to develop guidelines and administrative policies for pre-authorization. Insurance companies most likely subject the following kinds of drugs to PA:
- Brand name medicines that are available in a generic form
- Expensive medicines, such as those needed for psoriasis or rheumatoid arthritis
- Drugs used for cosmetic reasons such as medications used to treat facial wrinkling
- Drugs prescribed to treat a non-life-threatening medical condition
- Drugs not usually covered by the insurance company, but said to be medically necessary by the prescriber
- Drugs usually covered by the insurance company but are being used at doses higher than normal
Blue Cross Blue Shield requires prior authorization for those drugs that:
- have dangerous side effects
- are harmful when combined with other drugs
- should be used only for certain health conditions
- are often misused or abused
- are prescribed when less expensive drugs might work better
How long does prior authorization take?
Obtaining prior authorization for medication is a time-consuming process for physicians and their staff. According to AMA’s prior authorization survey 2023, physicians and their staffs spend 12 hours per week completing PAs. Typically, the pre-authorization process can range from a few days to weeks for a successful result, but may take longer in some cases. The time it takes for prior authorization to be successfully completed depends on numerous factors such as type of medicine, the payer’s rules, and the communication speed between the healthcare provider and insurance company. The main factor influencing the decision for PA approval is the quality of the healthcare provider’s documentation. Errors or discrepancies in the clinical notes, lack of information about previously tested medication or ambiguity about the state of patient’s disease could potentially lead to delay in the PA process. In the same AMA report, 27% physicians report that PAs are often denied. Further delays occur if coverage is denied and must be appealed. An appeal can take several days to process.
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