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I just enrolled in Medicaid, specifically the UnitedHealthCare Community Plan in New Jersey. Now most of the medications I'm currently taking are included in the Preferred Drug List, but there are a couple which are not on the list. To get the insurance company to pay for a drug that's not on the list, the doctor needs to fill out a Prior Authorization request, and then the insurance company needs to approve the request.

My question is, how likely is it for the insurance company to approve the Prior Authorization request? Here's what the Member Handbook of the plan says:

The drugs in the UnitedHealthcare Community Plan PDL have been selected to provide the most clinically appropriate and cost-effective medications for patients who have their drug benefit administered through UnitedHealthcare Community Plan. It is also recognized that there may be occasions where an unlisted drug is desired for the proper medical management of a specific patient. In those infrequent instances, the prior authorization process reviews requests for unlisted medications the physician may consider medically necessary for patient management....

A prior authorization request form is available in the UnitedHealthcare Community Plan provider manual and should be used for all prior authorization requests if possible. Appropriate documentation must be provided to support the medical necessity of the non-PDL request. The UnitedHealthcare Community Plan Pharmacy Department will respond to all requests in accordance with state requirements.

But that's just boilerplate. Can anyone tell me in practice, how likely it is for my prior authorization to get approved? Do insurance companies tend to be stingy about this sort of thing, especially in a Medicaid plan? Or do the "state requirements" for Medicaid alluded to in the quote above ensure a high rate of approval?

  • I believe prior authorization requests are required to be evaluated on purely medical criteria, not which plan you're on, but I'm not finding the right set of Google terms to confirm/deny this. – ceejayoz May 11 '17 at 19:55
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There is no way to give a percent chance of getting it approved. It will depend on the medicines involved, the options for generics or other cheaper drugs, and what has been tried before.

When I have had to do this with an employer plan: sometimes we won approval, and sometimes we didn't. I was able to in one case post-denial of the request I talked to a person at the insurance company and explained my case, and they ended up approving it.

The best chance is when the doctor is willing to document a true medical need for drug X, or a medical need to avoid drug Y.

The UnitedHealthcare Community Plan Pharmacy Department will respond to all requests in accordance with state requirements.

This line says that the state requirements dictate how long they have to respond to your request. They could approve or reject tour request, but they only have a specific window of time to do so. The state requirements may also dictate the specific method of contacting you.

  • But does the fact that this is a Medicaid plan impact the chances of approval? Would UnitedHealthcare be stingier (or less stingy) with Medicaid patients compared to those enrolled in employer-based healthcare? – Keshav Srinivasan May 11 '17 at 14:08
  • Also, when deciding whether to approve a prior authorization, does the insurance company look at how many prior authorizations they've approved for you already? I'm wondering whether I should limit my number of prior authorization requests, or if it doesn't matter if I make a lot. – Keshav Srinivasan May 11 '17 at 17:22

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