Prior authorizations are a routine part of many pharmacy benefits and a topic members ask us about often.

 

What is a prior authorization? 

A prior authorization is a review that happens before certain medications are covered. It helps confirm the clinical efficacy, appropriateness, and safety of the medication being prescribed for your specific condition.  

 

Why are they needed?

Some medications are very costly, have specific safety requirements, or are only approved for specific uses. Prior authorizations help: 

• Ensure you’re getting the right medication for your condition 
• Promote safe, effective, and adherent medication use 
• Keep overall drug costs as low as possible  

How do you get one? 

In most cases, your doctor submits the prior authorization request on your behalf, along with the medical information needed for review. Once we receive it, our clinical team reviews the request as quickly as possible and shares the decision with your provider. 

 

That said, there are a few simple ways you can help expedite the process: 

• Ask the right questions. If your doctor prescribes a new medication, ask whether it requires a prior authorization so the request can be submitted right away. 
• Confirm submission. If there is a delay at the pharmacy, check with your provider’s office to make sure the PA request has been sent. 
• Provide resources. Our prior authorization form is available directly on our website at pbdrx.com/members, easily accessible for both you and your provider.  
• Stay in touch. If your doctor needs additional information from you, responding promptly can help avoid delays. 

Understanding how prior authorizations work helps you play an active role in your care, and can make getting your medication smoother and faster.

 

Our role:

As your trusted pharmacy benefit manager, PBDRx is here to support you and help protect your health. Our clinical and service teams work closely with providers to review requests efficiently and are always available to answer questions along the way.  

Connect

You can learn more about your pharmacy benefit and explore helpful resources anytime at pbdrx.com/members. As always, if you have specific questions about your coverage, Pharmacy Benefit Dimensions Member Services Department is available Monday through Friday from 8 a.m. to 11 p.m. ET. at (716) 635-7880 or 1-888-878-9172 (TTY/TDD users can call 711).