If a Prior Authorization is required, your pharmacy will initiate a PA and the practice will submit the required information. The PA will then be reviewed by your insurance and either APPROVE or DENY it. If approved the pharmacy will automatically fill the prescription. The turn-around time varies significantly, where some PAs can move as quickly as within a few hours, but others can take up to a week or two.

However, if the PA is denied, your provider will examine the options and/or formulary alternatives provided by the insurance. Keeping the best interest of your child in mind, the provider will decide if the options are bio-equivalent and suitable, or if the original prescription remains being the best option.  If the latter is the case, you, as the parent, will have the option to either: 1) initiate an APPEAL of the insurance’s decision OR 2) pay for the prescription out of pocket.

If you opt to pursue an appeal, the insurance will provide you instructions on how to proceed when they send you their denial notification. You are responsible for initiating the PA Appeal process as well as following-up on the progress. Our practice will provide all of the corroborating information you need to build your case (letter of justification, child’s history, etc.), but you will need to communicate this need to us via patient portal, as the insurance will not inform us of this. If you have questions, please feel free to contact our Clinical Coordinator, Monica Larrieu at MLarrieu@northernvirginiapediatrics.com should you have any questions.