Medication Refill & Prior Authorization Policy

How to Request a Refill

Refill requests may be submitted through any of the following channels:

• Healow Patient Portal — Log in to your Healow account and submit a refill request. This is the fastest and most reliable method.
• Phone — Call our office at 770-458-8497 during normal business hours.
• Pharmacy Fax — Ask your pharmacy to fax a refill request directly to our office at 770-220-2839.

Most Refills Require an Appointment

Most prescription refills cannot be processed without a scheduled appointment. Controlled substance prescriptions require an appointment every time, without exception.

Prescribing a medication is an ongoing clinical responsibility — not a one-time decision. Each refill requires your provider to evaluate your current health status, assess whether the medication is still appropriate for your condition, identify any new side effects or drug interactions, and review the results of any relevant lab work. This evaluation is a standard of safe prescribing practice and is required regardless of how stable your condition may appear.

Regular follow-up also allows your provider to monitor for changes that are not always apparent to the patient — including lab abnormalities, early signs of medication-related complications, or shifts in your condition that may require a dosage adjustment or change in therapy. Continuing a prescription without this clinical oversight would not meet the standard of care we are committed to providing.

Prescriptions are written to last until your next scheduled appointment. When you are approaching the end of your supply, that is your cue to schedule your follow-up visit.

As a general clinical guideline, chronic conditions such as diabetes, hypertension, heart disease, and mental health conditions require provider evaluation every 3 months. Conditions that are not well controlled may require more frequent visits. Your provider will advise you on the appropriate interval for your specific situation.

Telehealth Option for Refills

When an in-person visit is not possible — such as when you are traveling, your schedule does not permit an office visit, or your refill need is urgent — a telehealth visit with Dr. Challa may be an appropriate option. During a televisit, your provider can clinically evaluate your current medication regimen, assess effectiveness and tolerability, address any side effects or concerns, and make prescribing decisions as appropriate for your situation. Please call our office at 770-458-8497 or log in to the Healow portal to request a telehealth appointment.

Lab Work and Medication Management

Lab work is mandatory for certain medications. Routine monitoring is required to evaluate how your body is responding to treatment, detect potential medication-related complications early, and ensure dosing remains appropriate over time. Your physician will review your results and adjust your dose or change your medication when clinically indicated. It is essential that ordered lab work be completed in a timely manner so that your provider has the necessary clinical data available at your next visit.

Processing Time

Please allow a minimum of 3 business days for all refill requests to be reviewed and processed. Requests submitted on weekends or holidays will begin processing on the next business day. Do not wait until you have run out of medication before requesting a refill. Request your refill at least one week before your last dose.

Urgent Refill Needs

If your refill need is urgent, you may be seen as a walk-in patient during office hours, or a telehealth visit may be arranged. Please call ahead at 770-458-8497 so we can prepare accordingly.

Controlled Substance Refills

Controlled substance prescriptions are subject to additional requirements under Georgia and federal law:

• A current in-person visit is required every time before a controlled substance refill is authorized
• Controlled substances will not be refilled or authorized after hours or on weekends
• Early refills are not permitted under Georgia law
• Lost or misplaced controlled substance prescriptions are handled on a case-by-case basis at the sole discretion of your provider. Please contact our office at 770-458-8497 to discuss your situation. We cannot guarantee replacement in all cases.

What Is a Prior Authorization?

A prior authorization (PA) is a requirement by your insurance company that your provider obtain advance approval before a specific medication will be covered. Insurance companies use prior authorizations to verify that a prescribed treatment meets their criteria before they agree to pay for it.

This policy applies to medication prior authorizations only. We are not able to submit prior authorizations for medications or services ordered outside of our practice. If you have questions about authorizations for services ordered by another provider, please contact that provider's office directly.

Medical Necessity vs. Insurance Coverage — These Are Not the Same Thing

Who Decides What They Determine Lenox Medical Clinic | 3042 Oakcliff Rd, Ste 200, Atlanta, GA 30340 | 770-458-8497 | lenoxmedicalclinic.com Page 2

• Your Physician (Dr. Challa) — What is medically necessary for your care
• Your Insurance Company — What is covered under your specific plan

These two determinations are made independently of each other. A prescription written by your doctor is not a guarantee that your insurance will pay for it. A denial does not reflect on the clinical judgment of your provider — it means the medication did not meet the specific financial or clinical criteria set by your insurance plan's coverage rules.

Why Do Insurance Companies Require Prior Authorizations?

Insurance companies use PAs as a cost-control measure. Common reasons include:

• The medication is a brand-name or higher-cost drug when a generic exists
• The prescribed dose or quantity exceeds standard coverage limits
• The medication requires documented evidence that other treatments were tried first (see Step Therapy below)
• The diagnosis requires clinical documentation to confirm it meets the plan's criteria

Step Therapy — Why You May Not Be Able to Start With Your Preferred Medication

Many insurance plans require a practice called step therapy (also called "fail first"). This means your insurance company requires you to try one or more lower-cost or preferred medications before they will approve a higher-tier or brand-name drug.

For example: your provider prescribes a brand-name medication, but your insurance requires you to first try a generic alternative. Only after documenting that the alternative was ineffective, not tolerated, or contraindicated will they consider approving the originally prescribed medication.

Our office must follow these legal and contractual protocols established by your insurer. We understand this is frustrating and we will do everything within our power to advocate for your prescribed treatment — but we cannot skip or override step therapy requirements.

Important tip: If you have previously tried similar medications and experienced side effects or treatment failures, tell us. This history is critical medical evidence that can help bypass step therapy requirements.

How the PA Process Works

Step 1 — PA Requirement Is Identified

A prior authorization requirement may be identified in one of two ways: our office identifies the requirement at the time of prescribing, or your pharmacy contacts our office directly with a notice that a PA is required before your prescription can be filled. In either case, our office will initiate the request.

Step 2 — We Submit Clinical Documentation

Our office compiles and submits the required documentation to your insurance company. This may include your diagnosis, treatment history, records of prior medications tried, lab results, and a letter of medical necessity. The time required to prepare this documentation varies depending on the complexity of your case and the specific requirements of your insurance plan.

Step 3 — Insurance Company Reviews the Request

Once submitted, your insurance company reviews the request. This process is controlled entirely by your insurer and typically takes 3 to 7 business days — though complex cases can take longer. Our office cannot expedite or rush an insurance company's internal review process.

Step 4 — Decision Is Made

Your insurance company will notify our office of their decision. We will contact you as soon as we receive a response.

The Insurance Company Has the Final Authority on Coverage Decisions

While our office will provide all required clinical documentation and advocate on your behalf, we do not have the power to overturn or override your insurance company's final coverage determination. Approval decisions rest solely with your insurance plan.

Your Role During the PA Process

• Call your insurance member services line (number on the back of your card) to confirm receipt of the PA and track its status.
• Make sure your insurance information on file with us is current and accurate — incorrect plan information is one of the most common causes of delays.
• Do not wait until you are out of medication — if your medication requires a PA, contact us as early as possible.
• Respond promptly if our office contacts you requesting additional information.

A denial is not always the end of the road. Here is what happens next:

Option 1 — Peer-to-Peer Review

Our office may request a peer-to-peer review — a direct conversation between Dr. Challa and a medical reviewer at your insurance company. Dr. Challa can present the clinical rationale for your prescribed medication and advocate for approval. We will pursue this when we believe it is clinically warranted.

Option 2 — Member Appeal

You, as the insured member, have the right to file an appeal directly with your insurance company. In many cases, a member appeal submitted by you personally can be equally or more effective than a physician review. To file an appeal: call member services and request the formal appeals process; ask for the specific reason(s) for denial in writing; request any forms required to submit your appeal. Our office can provide supporting clinical documentation to accompany your appeal upon request.

Option 3 — Formulary-Equivalent Alternative

If a PA is denied and an appeal is unsuccessful, Dr. Challa will work with you to identify a covered alternative — a different medication that is clinically appropriate for your condition and covered under your plan.

Option 4 — Manufacturer Assistance Programs

If your medication is not covered and no suitable alternative exists, most pharmaceutical manufacturers offer co-pay assistance programs, patient assistance programs, or other financial support options for eligible patients. Our staff can help point you toward available resources for your specific medication.

We understand how stressful it can be when a medication is delayed or denied. Our team spends significant time every week submitting documentation, following up on pending authorizations, and advocating for our patients.

Please be aware: Our administrative staff cannot override insurance rules, bypass formulary requirements, or speed up an insurance company's internal review. Delays caused by your insurer's review process are outside our control. We ask that all patients treat our staff with courtesy and respect — they are your advocates in this process. Abusive or threatening behavior toward our staff is not acceptable and may result in discharge from our practice consistent with our Patient Conduct Policy.

Why does my insurance need "permission" to fill my prescription?

Insurance companies use prior authorization as a cost-control measure. They want to confirm that a lower-cost option is not available before agreeing to pay for a more expensive medication. This is a payer requirement, not a practice requirement.

If my doctor says I need it, why would insurance say no?

Insurance companies create their own clinical criteria, which may differ from current medical guidelines. A denial does not reflect on the clinical judgment of your provider — it means the medication did not meet the specific benchmarks set by your insurance plan's formulary or coverage rules.

What is a formulary?

A formulary is your insurance plan's approved list of covered medications. Drugs are placed into tiers — lower tiers are less expensive for you, higher tiers cost more or may require a PA. If a drug is non-formulary, your insurer will almost always require a PA and may still deny it if a preferred alternative has not been tried.

How long will my PA take?

Once our office submits the request, your insurance company typically takes 3 to 7 business days to respond. Complex cases can take longer. You can check the status directly by calling the member services number on your insurance card.

Can I speed up the process?

The best thing you can do is make sure your insurance information on file with us is accurate, respond quickly if we contact you for additional information, and let us know if you have previously tried similar medications. That treatment history is critical for bypassing step therapy requirements.

What if I've tried similar medications before and had side effects?

Tell us. This is exactly the kind of medical evidence that helps us demonstrate why step therapy alternatives are not appropriate for you and supports approval of your prescribed medication.

My prescription ran out and my PA is still pending. What do I do?

Call our office at 770-458-8497 immediately. Depending on the situation, your provider may be able to see you as a walk-in or schedule a telehealth visit to discuss a short-term plan while your PA is being processed.

Why won't the office submit a PA for a medication my other doctor prescribed?

We are only able to submit prior authorizations for medications that Dr. Challa has prescribed and is actively managing. For medications ordered by another provider, please contact that provider's office to submit the authorization.