Prior Authorization and Pharmacy Changes
No, a prior authorization does not need to be redone when a patient changes pharmacies—the PA is tied to the patient's insurance coverage and prescription, not to a specific pharmacy location. 1
Understanding Prior Authorization Fundamentals
Prior authorization is a managed care requirement that validates insurance coverage for specific medications based on clinical criteria and formulary status. The PA approval is linked to the patient's insurance plan and the prescribed medication, creating a coverage determination that remains valid regardless of which pharmacy dispenses the medication. 1, 2
What Happens When Changing Pharmacies
When a patient switches pharmacies, the following process occurs:
- The existing PA approval remains active and valid as long as the prescription details (medication, dose, quantity, prescriber) remain unchanged 3
- The new pharmacy can verify the existing PA status through the patient's insurance plan's system 4
- The prescription simply needs to be transferred or re-sent to the new pharmacy location—no new PA submission is required 5
Critical Caveats and Common Pitfalls
Avoid assuming the PA needs resubmission just because the pharmacy changed—this creates unnecessary delays in medication access and administrative burden. 1, 4
Key situations that may require attention:
- If the prescription has expired or needs renewal, the PA may need reverification depending on the insurance plan's policies 5
- If medication details change (dose, quantity, formulation), a new PA may be required regardless of pharmacy location 3
- Some specialty pharmacies have specific network requirements—verify the new pharmacy is in-network for specialty medications 3
Practical Implementation Steps
To ensure smooth medication continuity when changing pharmacies:
- Send the prescription to the new pharmacy 1-2 days in advance to allow time for PA verification and medication ordering if needed 6
- Confirm the new pharmacy can access the existing PA approval through the insurance system before the patient needs the medication 6
- Verify the new pharmacy stocks the medication or can order it promptly, particularly for specialty or less common medications 6
- For specialty medications, confirm the new pharmacy is authorized to dispense that specific drug class 3
When PA Reverification May Be Needed
Distinct from a pharmacy change, these scenarios require PA attention:
- Annual PA renewals based on insurance plan policies—typically required every 6-12 months regardless of pharmacy 3
- Changes in insurance coverage or plan formulary status 1
- Medication dose adjustments or formulation changes 3
- Transition between care settings (inpatient to outpatient) may require new PA submission 3