Understanding the insurance authorization process for fertility treatment specialty medications

Often as nurses, we are called upon to engage in sometimes lengthy, spirited debates with insurance companies in order to obtain prior authorization for medications commonly used during treatment cycles. We thought it would be helpful to review what the process on our end is.

When we call to obtain prior authorization, we have to complete several forms for the insurance company and submit them with treatment plans. Sometimes we can complete the required information online, and if that option is available, we use it. After the forms are done – we wait. And wait. And call. Then we call again to see what the holdup is. The insurance companies don’t always see the urgency involved in getting that magical authorization number in your file. That number is needed before we can actually order the medications.

Don’t hesitate to call the insurance company yourself  – they are in business for YOU!

Although it’s not required, it certainly can help the process if you call the insurance company to follow up and nudge them along. We have found that when we do our stuff, and you call on your end to add a little more pressure, you can actually get your medications sooner. So, don’t hesitate to call the insurance company yourself. You are the one paying for their services – they are in business for YOU!

Most of the specialty pharmacies are ones that will send your order through the mail so allow time for them to be processed.

Because of the nature of injectable medications, they are considered specialty medications. This means that they can’t be obtained at your local pharmacy. They need to come from either the insurance-specific pharmacy or from a local specialty pharmacy. Having said that – you must allow time for the medications to be processed and delivered to you. Most of the specialty pharmacies are ones that will send your order through the mail. There are a couple of local places we can call, but they may or may not be covered by your insurance plan.

Begin the process 2 weeks prior to the start of your cycle.

A good rule of thumb to keep in mind is to begin the process of obtaining your medications about 2 weeks prior to the start of your cycle. This way, there is time for us to get the authorizations needed and place the order, and for you to coordinate the payment and delivery. The process is not always without frustration, and we get it. We are always on your side and happy to help with anything we can. Don’t wait until the last minute to think about your meds. Start the process early. Doing this can only reduce stress and make the process at least a little bit easier!

- Nursing Coordinator, Sam Smith R.N

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