Prior authorization is a health plan's review before it agrees to cover certain care or medications. It is separate from your prescriber's treatment decision. HealthCare.gov definition
How OnPoint helps
We identify coverage requirements, share available plan information with your prescriber's office, help gather relevant pharmacy records and follow up on the next steps. We keep the roles clear: the prescriber provides clinical information, the appropriate requester follows the plan's submission process, and the plan decides coverage.
Who sends the request?
The rules depend on the plan. For Medicare Part D, a patient, prescriber or permitted representative may request a coverage determination. That does not authorize a dispensing pharmacy to submit under every other program. CMS coverage determinations
For NYRx, ordinary requests must come from a prescriber or NYRx-authorized agent. Dispensing pharmacists cannot initiate these requests for prescribers. The manual describes a limited emergency-supply exception, which a pharmacist must assess under the applicable rules. NYRx pharmacy manual, pages 14–15
Timing, cost and next steps
Ask your plan or prescriber about the deadline that applies to your request and whether an expedited review is appropriate. OnPoint cannot promise an approval date, price or coverage outcome. An approval does not by itself confirm payment, stock or eligibility to dispense.
If the plan denies coverage, ask for the written reason and appeal instructions. Your prescriber and you can discuss an appeal or another treatment. Contact your pharmacy and prescriber promptly if you may run out; do not wait for a website response.