Quick Guide to CoverMyMeds Prior Authorization Requests

By automating part of the process that providers and pharmacists use to submit prior authorization requests, CoverMyMeds helps patients get medications faster compared to phone and fax methods.^{[0]CoverMyMeds data on file, 2018}

Insurance plans use prior authorization requests to make coverage determinations and to verify clinical decisions of healthcare providers. When a prior auth is required for a prescription medication, providers must fill out a request form and send it to the payer or pharmacy benefit manager (PBM) for a determination.

A prior authorization request requires your prescriber to confirm that the patient needs this exact medication based on lab ranges, prior treatment steps taken or other factors, and gives the insurance plan more context as to why the medication should be covered.

CoverMyMeds is available at no charge for healthcare providers, and today more than 950,000 providers use CoverMyMeds to electronically submit prior auth requests to every health plan. If you’re ready to start making the prior auth process more efficient, here’s a quick overview of how CoverMyMeds can help.

HOW DOES COVERMYMEDS MANAGE THE PRIOR AUTHORIZATION WORKFLOW?

With CoverMyMeds, healthcare teams can submit electronic prior authorization requests for any medication and all plans. You can also renew previously submitted prior auth requests.

Prior auth determinations are often received in real time, helping to avoid medication access delays. You can also keep patients who consent to receive notifications in the loop with email and text messages regarding their prior auth determinations.

WHAT DRUGS AND HEALTH PLANS DOES COVERMYMEDS WORK WITH?

CoverMyMeds’ solutions work for all drugs, including specialty medications, and all health plans and PBMs, including Medicare Part D and Medicaid. Our electronic services, including electronic prior authorization (ePA) and specialty patient support services are available at no cost for prescribers and their staff. (Read about how to simplify GLP-1 prior authorization with CoverMyMeds.)

HOW DOES COVERMYMEDS SUPPORT PRIOR AUTH FOR GLP-1 DRUGS?

Prior auth for GLP-1 drugs often involves complex documentation, with different required criteria across insurers. By submitting prior auth requests electronically with CoverMyMeds, you may reduce the time-consuming back-and-forth traditionally associated with manual methods such as phone and fax.

As more insurers require prior auth for GLP-1 drugs, prescribers and their staff may want to consider initiating prior auth request at the time of prescription, to help get ahead of potential delays at the pharmacy. (Read about 5 ways care teams are navigating 2025 health benefit changes.)

Additionally, CoverMyMeds may offer real-time access to drug benefit coverage information. This further helps prescribers to initiate prior auth requests during patient appointments, thus reducing medication access delays.

HOW TO CREATE AN ACCOUNT ON COVERMYMEDS.HEALTH

When you make your account at covermymeds.health, you’ll be prompted to enter several pieces of information. You can update these details any time by clicking “Account” on the left side of your home page and then select “Profile.”

Enter the following information:

• Name, work email address, job title, credentials and role in the office
• Your familiarity with CoverMyMeds and the prior authorization process
• Office fax number, phone number, mailing address, office type and EHR vendor
• A username and password

HOW TO ADD PRESCRIBERS TO YOUR ACCOUNT

By adding your office’s prescribers to your account, pharmacy-initiated prior auth requests will automatically appear in your dashboard where you can open and complete them without a key.*

• Click “Verify Prescribers” on the left side of your account homepage.
• Search for the prescribers in your office by name or National Provider Identifier (NPI) number and select the fax number you have access to.
• Get the fax from the fax machine selected and enter the code back into the Verifications page.
• That’s it — prior auth requests for verified prescribers will automatically be shared with your account and appear on your dashboard.

*A "key" is a six-to-eight-character alphanumeric code that uniquely identifies a specific prior authorization request. This key is prominently displayed at the top of the page in the blue bar after a request is opened. The key serves as a unique identifier, allowing healthcare providers, staff and pharmacies to track and manage individual prior auth requests efficiently.

HOW TO BUILD A PROCESS FOR RECEIVING PRIOR AUTH NOTIFICATIONS

We’ll notify your office every time a prior auth is created for one of your patients, so it’s important to make sure there’s a system in place for getting these notifications to the right person. To do this, we recommend:

• Designating a collection spot for new prior auth notifications sent via paper fax.
• Periodically checking that the fax machine listed on your profile is correct, and that the fax number for each prescriber in your address book is still accurate.
• If using an eFax system, manage your inbox to make prior auth notifications easy to organize.

HOW TO LOCATE THE CORRECT PRIOR AUTHORIZATION FORM

While most pharmacies using CoverMyMeds will initiate a prior auth request if one is required by the insurance plan, it’s important to have the right information on hand to start one if they don’t.

To find the top suggested prior auth form to use for a patient, follow these steps:

• Click “New Request” in the top left corner of your account homepage.
• Enter the medication name, patient demographic information and BIN, PCN and RxGroup (these can be found on the patient’s prescription insurance card).
• Choose a form from the list that populates and click “Start Request.”

HOW TO COMPLETE PHARMACY-INITIATED PRIOR AUTH REQUESTS

Integrated with 50,000+ pharmacies nationwide, CoverMyMeds supports the initiation of prior auth requests that pharmacies send to providers for completion. When a pharmacy starts a prior auth request for one of your patients, you will receive a fax with an access key and may also receive an email notification.

• Log into or create your CoverMyMeds account at covermymeds.health.
• On your CoverMyMeds dashboard, select “Enter Key.”
• Enter your key, your patient’s last name and date of birth, as indicated on the fax. You’ll see that some of the prior auth request has been auto-populated based on pharmacy claim information.
• Complete the remaining fields, including the option, with patient consent, to enable auto-sharing of prior auth determination with your patient and then select “Send to Plan.”
• If the insurance plan sends the determination via fax, you can mark the response directly in your CoverMyMeds account. The pharmacy will then be notified of the outcome.

WHY CONSIDER INITIATING PRIOR AUTHORIZATION REQUESTS AT THE TIME OF PRESCRIBING?

Many provider's offices only start a prior auth request retrospectively, when the pharmacist initiates the request after a claim has been rejected. But if a patient goes to the pharmacy and chooses not to pick up their prescription due to the lack of insurance coverage, the retrospective prior auth request process creates an extra administrative step for staff which may delay a patient starting their prescribed therapy.

With CoverMyMeds, providers can easily initiate prior auth requests without waiting on the pharmacy. Beyond the added efficiency for providers, our research also shows that patients access their medications 13.2 days sooner on average when prior auth requests are initiated prospectively at the provider’s office.^{[0]CoverMyMeds Provider Surveys, 2019, 2020, 2021, CoverMyMeds data on file}

The Provider-Initiated Prior Auth Request Process:

1. The provider completes the prior auth at the time of prescribing and sends the prescription to the pharmacy.
2. The patient’s health plan reviews the prior auth request and provides a determination.
3. If the prior auth is approved, the pharmacy can run the claim and fill the medication.

HOW TO SIGN UP PATIENTS FOR AUTOMATIC NOTIFICATIONS ON PRIOR AUTHORIZATION DETERMINATIONS

In the same workflow used to initiate a prior auth request with CoverMyMeds, providers can sign patients up to receive email and/or text notifications on prior auth determinations. According to our patient survey, 94% of patients appreciated knowing about their prior auth outcome.^{[0]CoverMyMeds PA Notify data for approved PAs, 2022} For qualified therapies, healthcare providers can follow these steps:

1. Start a prior auth request at covermymeds.health or open a pharmacy-initiated request.
2. With patient consent, select the option on the prior auth request page to inform patients of their prior auth determination.
3. Enter the patient’s contact information.
4. Send the prior auth request to the plan. Once the plan determination is received, both your office and the patient are notified.

Read more about patient prior auth request notifications.