WHAT IS A PRIOR AUTHORIZATION?
Some treatments need approval from your insurance plan before the plan will consider paying for them. This process is called prior authorization. It may also be called pre-certification or pre-approval.
WHY IS A PRIOR AUTHORIZATION NEEDED FOR A MEDICINE?
A prior authorization confirms that your prescribed medicine is medically necessary. Prior authorizations help insurance plans reduce costs, prevent unnecessary treatment, and ensure medicines are used safely.
Receiving a prior authorization approval shows that your insurance plan believes your medicine is appropriate for you. At that point, your insurance plan decides how much of the cost it will cover.
WHAT ARE THE STEPS FOR A
PRIOR AUTHORIZATION?
- Your insurance plan informs your doctor that a prior authorization is needed
- Your doctor typically sends a prior authorization request form and certain health records to your insurance plan electronically or via fax
- Your insurance plan reviews this information and decides if a prior authorization is approved
- Your insurance plan may ask your doctor for more information before deciding
The prior authorization process usually takes less than a day, but it sometimes may take up to a week or longer.
WHAT IF MY INSURANCE PLAN SAYS NO?
Sometimes, an insurance plan issues a denial, also called an adverse benefit determination. A denial is not always a firm "no." If your doctor believes your medicine is necessary, the insurance plan's decision can be appealed.
The appeals process varies from plan to plan. Your doctor can usually appeal by sending a form or letter to your insurance plan electronically or via fax. Your doctor may also be able to talk to someone at your insurance plan over the phone or in a virtual meeting. 60% of denied prior authorizations for NUBEQA are approved upon appeal.
WHAT STEPS CAN I TAKE?
Your doctor will request a prior authorization on your behalf, but there are steps you can take to help ensure you receive the medicines that you and your doctor decide are right for you:
- Call your insurance plan to ask for the prior authorization criteria and write them down to share with your doctor, if needed
- If you have waited for 1 week or more, call or message your doctor’s office and your insurance plan about the status of your prior authorization
- If you receive a denial, tell your doctor that you want to appeal
- Call your insurance plan to confirm appeal processes and deadlines
- Keep detailed records, including notes from phone conversations and copies of all forms
WHO CAN I ASK FOR HELP?
Bayer is here to support you as you take the next steps. Access Services by Bayer™ is a free support program for enrolled patients prescribed NUBEQA. Your Access Services by Bayer Case Manager can*:
- Provide you with financial support options to help pay for NUBEQA, if you are eligible
- Refer you to charitable foundations, if you are eligible
- Refer you to the Bayer US patient assistance program, if you are eligible
- Help you navigate prior authorization, which your doctor will complete if your insurance requires it
Enroll in Access Services by Bayer in your doctor’s office. Ask your doctor about a free 1-month supply (new patients only) and a NUBEQA Patient Starter Kit.
*Co-pay assistance cannot be offered to Medicare, Medicaid patients and those treated at Veterans Affairs (VA). Additionally, samples and the 1-Month Free Trial program cannot be used in the VA.
For support throughout your treatment journey, including help with prior authorizations and appeals, connect with these patient advocacy organizations:
If you are an enrolled patient who has been prescribed NUBEQA and you have questions, call Access Services by Bayer at 1-800-288-8374
Monday-Friday, 8:00 AM-8:00 PM (ET)
Enroll in Access Services by Bayer in your doctor’s office.
