Increasingly, prior to agreeing to pay for a prescription that your doctor has written specifically for you, insurance companies require that they be allowed to pre-approve the details of that prescription, even if the drug in question is on the list of drugs that particular insurance company will cover. The process for acquiring this approval is called a "Prior Authorization"; it can and often does involve multiple lengthy phone calls and appeals on your behalf. Furthermore, approval of a Prior Authorization for a particular prescription does not mean that your insurance company will approve the same prescription in the future. Most insurance companies require that the process be repeated anywhere from every two months to once a year.
If/when your insurance company requires a Prior Authorization, your pharmacy will fax us a request. Marina Medical is not privy to and cannot be responsible for the communications between you and your pharmacy or insurance company or between your pharmacy and your insurance company. When we receive a request from your pharmacy for a Prior Authorization, we must presume that you are aware of the request and that you want us to proceed with the process in a timely manner. If you want to ensure that your pharmacy first notifies you about your insurance company's requirement of a Prior Authorization, it is your responsibility to clarify your desire with your pharmacy.
Upon receipt of a faxed Prior Authorization request from your pharmacy, Marina Medical will send you an acknowledgment thru your online portal. Marina Medical will initiate the approval process with your insurance company within 24 hours of receipt of the request, weekends and holidays excluded. Charges for this service are detailed below and will be identified in the acknowledgment sent to your online portal.
Payment for each Prior Authorization request is due upon receipt of the request from your pharmacy. Unless other prior arrangements have been made, Marina Medical will charge your credit card on file. If you wish to provide another method of payment, you must notify us immediately when the Prior Authorization request is initiated; call the clinic or send the change request thru your online portal.
In case of a denied credit card payment by your bank - if no other payment arrangements have been made - Marina Medical will close that particular Prior Authorization and no further action will be taken. Notice of closure of the Prior Authorization will be sent to you thru your online portal.
Marina Medical cannot guarantee the outcome of any Prior Authorization process. Marina Medical will work hard to obtain approval of your prescription as written by your physician. As noted above, this sometimes involves multiple phone calls and - within reason - appeals to resolve denials by the insurance company. Sometimes we are able to obtain approval by making a relatively minor modification of the prescription; most patients prefer this to not receiving coverage by their insurance. In that instance, Marina Medical will first notify you of the proposed modification and obtain your consent to proceed with the Prior Authorization for the modified prescription.
If for any reason additional information from you is required - by your insurance company, your pharmacy or Marina Medical - to continue the Prior Authorization process and you fail to provide it, the Prior Authorization will be closed and no further action will be taken by Marina Medical. Such additional information could include, but not be limited to, updated or modified insurance policy details or additional laboratory testing which may require a visit to the clinic.
Once Marina Medical has initiated the Prior Authorization process for your prescription, the charge applies regardless of the outcome, i.e. whether or not your insurance company eventually approves your prescription as written and whether or not you provided any required information.
If you do not wish to have a specific Prior Authorization processed, you are required to contact Marina Medical to cancel the request within 24 hours of the time your pharmacy initiated the Prior Authorization process by faxing the request to Marina Medical. If your credit card has been charged, the charges will be reversed. Acknowledgment of your timely cancellation request will be provided to you thru your online portal.
Prior Authorization Fee Schedule
It is our hope that implementation of this Prior Authorization Policy and your cooperative compliance with it will enable us to provide you with better service at a reduced cost. To that end, as of December 8, 2015, we are reducing our charges for processing your Prior Authorizations to the following schedule:
Fee for each Prior Authorization for a
medically-necessary high-dose controlled substance: $55.00
Fee for each Prior Authorization for all other controlled substances: $45.00
Fee for each Prior Authorization for a non-controlled substance: $30.00
Depending on circumstances, we reserve the right to modify charges. You will always be advised of the exact amount in the acknowledgement sent to your online portal when the Prior Authorization is initiated. At that time, you have the opportunity to opt out of the Prior Authorization process and associated fees for that prescription.
My signature below indicates that I have carefully read the entire Marina Medical Prior Authorization Policy, and that I agree to abide by all its provisions.
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