Getting Specialty Drugs Approved

How prior authorization and exceptions work for expensive medications.

Expect paperwork

Specialty drugs often need prior authorization, step therapy, or quantity limits. Start the process as soon as your clinician prescribes the drug.

Ask which specialty pharmacy the plan requires — using the wrong pharmacy delays fills.

If denied

Request the denial reason, ask your clinician for a peer-to-peer review or exception, and check manufacturer assistance programs.

When comparing plans, map your exact specialty drug on each formulary before Open Enrollment ends.

Next step

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Frequently asked questions

Do copay cards help?
Sometimes for commercial plans, but accumulator programs may block deductible credit. Ask.
Can I fill at any pharmacy?
Specialty drugs often must go through a designated specialty pharmacy.

Sources