The Pharmacist’s Role in the Prior Authorization Process

The processes for prior authorizations continue to grow year after year. And with the need to decrease costs being greater than ever, many health plans are still continuing to increase the number of prior authorizations that are required for both medical and prescription benefits.

Prior authorizations are used by insurance companies to determine whether or not a policyholder is able to receive coverage for healthcare. This is often a complex process that involves several different parties including the patient, healthcare provider, insurance company, and the pharmacy (to learn more about the prior authorization, check out this blog post).

In today’s blog, we are going to be covering who can process prior authorizations, what the pharmacist’s role is in the process, and whether or not a prior authorization can become a function of pharmacy practice. Read on to learn more, and if you are looking to have prior authorizations outsourced for your medical practice, be sure to reach out to our team at AuthNet today for a free demonstration of our prior authorization services.

Who processes prior authorizations?

The providers who are able to process prior authorizations will depend greatly on your area of practice as well as your employer. When it comes to pharmacists, many are currently denying contribution to the processes, but some of the processes are integrated into the workflow.

Retail Pharmacies

For example, when Medicare Part B information for Blood Glucose Test Strips and other glucose testing products is submitted by a pharmacy, a prior authorization is conducted in almost all instances. Many large pharmacy chains will contribute to these processes and submit any additional information and documentation for these Medicare Part B approvals, involving them in the prior authorization process.

Independent Pharmacies

On the other hand, some independent pharmacies provide even more comprehensive prior authorization services to local prescribers in order to ease the administrative burden and see larger reimbursements. This requires collaboration from the prescribers and their staff as additional clinical documentation and/or chart reviews are needed. These individuals also need to keep in mind their local regulations and HIPAA releases that are involved in collaborating on patient care in order to ensure that they are following all guidelines appropriately.

Specialty Pharmacies

Specialty pharmacies will process prior authorizations from start to finish in some cases for prescribers. This is often due to the fact that medications are expensive and the pharmacy will see the direct reimbursement and revenue from the treatment at hand. With specific team members who are dedicated to prior authorization, patients can get access to their medications faster and, in turn, the pharmacy can get paid just as fast.

Clinical Pharmacies

There are also some instances where clinical pharmacists will take on, or at least contribute to, the prior authorization process. They are a member of the healthcare team and often have collaborative practice agreements. Prior authorizations can fit in this scope of their pharmacy [practice and increase the overall value of the practice.

The Benefits of Outsourcing Prior Authorizations

As you can see, pharmacists often play a large role in the prior authorization process, which can take away from their other daily responsibilities. At AuthNet, we saw this problem and took it into our own hands to streamline the process and make it easier and faster for healthcare providers, pharmacists, and patients alike. For more information about the benefits of outsourcing your prior authorizations with AuthNet, check out this post and give us a call today to learn more.

Can Prior Authorization Become a Function of Pharmacy Practice?

Put simply, yes. While it will take some work in order to get there, there is a good chance of this happening.

While prior authorizations are currently a common practice in specialty pharmacy settings, these best practices can also be translated to other areas of pharmacy. Specialty pharmacy invests in processing prior authorizations because the monthly drug spend for specialty products is commonly over $2K per patient — meaning that they decided to stop putting their finances into the hands of healthcare providers who have plenty of other things to do.

Pharmacies in these positions have also found that partnering with AuthNet to complete their prior authorizations helps to speed up the process, save money, and provide patients with faster results. Our prior authorization certified specialists (PACS) have the experience and training in order to help healthcare providers and pharmacists alike navigate the prior authorization process with ease and help patients get access to much-needed medication faster than ever. By utilizing a secure, HIPAA-compliant portal, we are able to track each request all the way through to approval, and if a claim is denied, we also manage follow-up, obtain additional records or details from your office, and send them over to the insurance company to be reviewed as needed.


Free up your time and streamline the prior authorization process with AuthNet today!