LM Jan 2024

OK, you know your health plan may require you to get prior authorization before it will cover certain drugs and medical services. But what exactly is prior authorization? Why do you need it? How do you get it? And what’s so important about it? Let’s break it down: What is prior authorization? It’s a review process your doctor must request—in advance— for you to get certain drugs or medical services, to make sure you meet certain requirements before the health plan agrees to cover the drug or service. Why do I need it? Prior authorization must be approved before you can get some drugs and services in order to ensure that you’re getting the appropriate care for your situation and that the care is of the best value. If you don’t get this approval, your drugs or services might not be covered by your plan. Note: You never need prior authorization in emergencies. How do I get it? Your doctor submits a prior-authorization request—before you get the drug or service/procedure—to your health plan’s Your Health Matters

Prior Authorization: What, Why and How? Submitted by Health Alliance™

Medical Management department for them to do a medical review. The review and approval process takes one to 14 business days, depending on the type of request and the level of medical urgency. Reviews for drugs generally don’t take longer than 72 hours and can be as fast as 24 hours. Reviews for medical services/procedures (if considered medically urgent) can take as little as 72 hours, but if they’re processed as a standard request, they can take up to 14 business days. They usually take less time, but some cases may require additional clinical documentation, which delays the process. In these cases, your health plan gets in touch with your doctor and asks them for that documentation. Once a decision is made—to either approve the drug or service, or to deny it—your health plan sends a letter to you and your doctor. If the request is denied, you have the right to appeal in writing within 60 days of the decision.

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To learn how Health Alliance can save your district money, contact your ISEBC agent:

Clemens and Associates, Inc.: tcockburn@clemensins.com (Egyptian, Shawnee, Kaskaskia, Southwestern and Wabash Valley)

American Central Insurance Services: jeremy@americancentralins.com (Abe Lincoln, Central Illinois Valley,

J. Krug: lsimios@jkrug.com

James Unland & Company, Inc.: bshock@unland.com (Western (Knox County) and Central Illinois Valley (Peoria, Tazewell and Woodford counties)

(Blackhawk, Kishwaukee (Boone, DeKalb and Winnebago counties), Northwest and Starved Rock)

Corn Belt, Illini, Kaskaskia, Two Rivers and Western)

*Health Alliance Medical Plans received the highest score in the Illinois/Indiana Region in the J.D. Power 2023 U.S. Commercial Member Health Plan Satisfaction Study of members’ satisfaction with their commercial health plan experience. Visit jdpower.com/awards for more details.

23 LM January 2024