You’ve just met your doctor (or licensed health professional), and they have given you a prescription for a very specific medication. You take it to your favorite pharmacy to fill it as usual, but then you get a shock! Your drug claim has been denied! This isn’t supposed to happen, you think, this is what my benefits coverage is for. So, you call your benefits provider, and they say you need a Special Authorization form (also known as a Prior Authorization form) signed by your doctor.

But what is this form? Why is it needed? What makes this prescription so different from all the others covered as usual? If the doctor prescribed the medication, shouldn’t it just be approved and covered by your benefits plan?

Typically, Benefit Plans will cover members up to the MAC Pricing (Maximum Allowable Cost), which is equal to the cost of the approved generic version of the drug. These MAC medications have similar active ingredients and are used to treat the same conditions as the more expensive brand-name versions. 

Stethescope and calculator

When you are prescribed a medication, sometimes the brand name medication comes with a very high cost or is considered non-standard or experimental. Though your benefits plan is designed to cover a broad range of services and medications, sometimes, not all scenarios can be accounted for.

If the brand-name version of the drug is truly essential to your care, a Special Authorization Form is required. Your doctor signs the form and indicates that this specifically named medication is necessary for your care, and the MAC version will not suffice.

These Special Authorization forms are an essential component of all health benefit plans, protecting both the patient and the stability of the benefits plan from unnecessarily high costs. These forms aren’t meant to dictate which medications you should or shouldn’t

take, but offer a balance between providing comprehensive healthcare coverage and managing the financial sustainability of the benefits plan. 

Illustration of Medications

The Prior Authorization Form acts as a sort of checks-and-balances. It helps evaluate whether the more expensive version is necessary and appropriate. It helps ensure that today's patients get the medication they require while ensuring the future of the benefit plans stays stable and secure.

If you are an ARTA member and wish to get a Prior Authorization Form, you can find one along with instructions by clicking here.