Understanding Prior Authorizations, Referrals and Rebates
– What is a prior authorization (PA)?
Under medical and prescription drug plans, certain medications may need approval from your health insurance carrier before they’re covered.
– How does the prior authorization process work?
Prior authorizations for prescription drugs are handled by your doctor’s office, your pharmacy, and your health insurance company. Your insurance company will contact you with the results to let you know if your drug coverage has been approved or denied, or if they need more information.
- Your doctor will submit the medication to the pharmacy of your choice via E-prescribe or will give you a handwritten prescription.
- It is your responsibility to go to or call your pharmacy to fill the medication/UPDATE your insurance information. This will initiate the PA process if one is needed.
- The pharmacy will contact your doctor’s office VIA FAX/PHONE if a PA is needed usually within 24-48 hours.
- Once the doctor receives the PA request forms, they will submit the PA accordingly.
- Your health insurance company will review your doctor’s recommendation and then either approve or deny the authorization request. They will contact you directly with the decision. An approval can take up to 14 business days.
– What if my prior authorization is rejected?
Typically within 1-14 business days, your health insurance company will either approve or deny the prior authorization request. If it’s rejected, you can ask for an appeal of the decision. Your doctor may also recommend an alternative medication for you.
– What if I want an update on the status of my prior authorization?
Virginia Eyecare Center will respond to any received PA requests within 3 business days. Virginia Eyecare Center will contact you via text once we have responded to a PA request.
If you have not received a text from us, the PA may be in process at our office. If the pharmacy tells you that they have sent the PA to our office, please allow us 3 business days to respond to the PA. If you have not heard from us via text within 3 business days of the pharmacy saying that they initiated the PA, then we have not received the PA. You should contact your pharmacy to initiate a PA again if one is needed. Make sure that the pharmacy has your updated insurance information and the correct contact information for Virginia Eyecare Center. If you have received a text from us, but have not yet received an approval or rejection, you can contact your insurance company to check on the status of the PA.
A referral is a kind of pre-approval that some patients-primarily those with health maintenance organization (HMO) or point of service (POS) plans-must obtain from their primary care physician (PCP) in order to visit a specialist or another doctor within the same network for a medical condition. Most PPO plans do not require referrals.
It is common that we see a patient using their vision plan (VSP or Eyemed) for their comprehensive annual eye exam, but then we may need to retain a referral from a patient’s PCP in order to see them for medical office visits.
If a patient does not obtain a required referral, their insurance plan will not pay for specialist medical care received. To avoid unexpected bills, a patient should get a referral from his/her PCP when required by the plan for medical visits.
Getting a referral does not guarantee the insurance plan will cover or pay for everything. For example, the patient may have a copay, may need to meet a deductible, or may be required to pay for things the plan doesn’t cover. However, without a referral, you could pay more or all of the costs.
Referrals expire. A patient might have anywhere from 90 days to one year to use a referral.
Virginia Eyecare Center will give you a bright-colored Request for Referral form if we recommend you return to us for a medical office visit and your insurance requires a referral. The form is NOT a referral but should be given to your PCP to help them prepare your referral.
The form contains the following instructions for the patient to follow:
INSTRUCTIONS FOR THE PATIENT: (Your insurance requires you to obtain a referral for a medical visit)
- Please take this form to your PCP/PCM as soon as possible to allow for processing time so that you can obtain a referral for your upcoming medical office visit.
- Please confirm that we have received a referral before you arrive for your appointment.
- Without a referral, we will be unable to submit to your insurance and you will be responsible for any out-of-pocket costs.
Contact Lens Rebates
A contact lens rebate is money back that many contact lens manufacturers offer when people purchase their products. The contact lens rebates are not instant rebates- you will initially pay full price for the contact lenses, and then will get a monetary reward from the contact lens company after submitting proper documentation. In order to claim the rebate and get money back, you are required to submit the rebate form online or mail it in with proper documents.
- Make a qualifying contact lens purchase eligible for rebate. (Year supply)
- Once you receive your contact lenses, you are now able to submit the rebate. Please keep in mind that manufacturers may have varying submission policies. Example: Submitting a rebate within 60 days of purchase date.
- In order to submit a rebate, you are required to have a rebate code, which is found on the rebate form Virginia Eyecare provides you. You are also required to upload images of the required documents via either mobile device or computer. Example of required documents are as followed:
- Receipts of dated eye exam and contact lens fitting exam
- Dated sales receipt of eligible contact lens purchase
- Two pictures of product box end panels
- Once you have successfully submitted your rebate, the next step is to wait for the manufacturer’s approval. If anything is missing, you will be contacted via email by the manufacturer. The rebate is from the manufacturer of your contact lenses, so please contact their customer service number for all rebate related questions. Virginia Eyecare Center only provides the rebate forms, we do not have anything to do with a rebate being approved or sent to you.
- You will NOT have to open, write on, or cut boxes to submit a rebate. We can exchange unopened, unwritten on, undamaged boxes of contact lenses within one year of purchase if your prescriptions changes in that time frame.