Medicare Prior Authorization Explained

Prior authorization means your doctor must get approval before providing certain services. Commonly, doctors must also obtain prior permission before prescribing certain medications. However, drug coverage is often plan-specific. Meaning, beneficiaries should contact their plan directly to confirm individual plan coverage.

CMS proposed a new ruling that targets reducing the burden on doctors. The rule suggests introducing prior authorizations electronically for Part D.

By 2021 CMS expects to see the support of the new Part D e-Prescribing program in all Part D plans. Seema Verma says, “improving patients’ access to prescription drugs is a top priority for CMS.”

The drugs your doctor may prescribe to treat you may need prior authorization. Therefore, your Part D plan won’t cover the costs of certain medications until you meet the conditions. Many plans use this process to ensure the proper usage of drugs. Approval and coverage vary between policies to determine which drugs are available.

If a plan doesn’t cover a medication, they have an alternative or similar drug on their formulary instead. This way, you still get proper treatment.

Medical insurance for services such as doctors’ visits, fall under Part B coverage. Medicare pays 80% of the approved costs of service, and the recipient covers the other 20%. Although, there’s a wide range of services and treatments that don’t require prior authorization with Part B. On the other hand, some need Part B approval before benefits start.

Part B covers the administration of certain drugs when given in an outpatient setting. Although, some meds may require your doctor to submit a Part B Drug Prior Authorization Request Form.

If the request gets approval, coverage begins.

Part D plans use drug restrictions as a form of prior authorization that costs low. These restrictions also help to protect beneficiaries. Limitations in the way of prior authorizations need approval before a patient may fill their prescription. Individual plans may restrict the quantity limits of members. Meaning, the policy only covers 30 tablets per 30 days.

Most Part D plans have Prior Authorization forms you can download online. The online option is a useful way to print the forms and take them to your doctor. Your doctor can help you correctly complete the form.

Also, recipients may contact Part D plans directly and ask for a mail-in form. The number for Member Services is on your plans’ member ID card.

Also, Medicare Advantage plans may need prior authorization to seek out-of-network and hospital care. Also, Advantage plans may require pre-approval before an enrollee may get a service or treatment. Sadly, if Medicare doesn’t approve the request – your plan typically doesn’t cover any of the costs. That leaves the full cost of service up to you.

Advantage members may appeal to their plan’s denial. However, most recipients don’t take advantage of approval requests.

Last year, reports showed that 4 out of 5 members with Advantage plans require prior authorization for certain services. 80% of enrollees must get prior approval for services at the highest allowable cost.

Meanwhile, more than 50% of all Medicare Advantage plans require pre-approval for mental health treatment.

Plan formularies state if your treatments require approval. Each plan has this information on their website. Recipients may also find more information in the Medicare & You handbook. The doctor’s office is responsible for requesting approvals. If you need a request, give your doctor all the information to meet the criteria.

Make sure you review with your doctor that any requests have a correct submission. Go over your plan’s terms and double-check the application before sending it for approval.

If your doctor believes your treatment is medically necessary, they can contact your plan and request an exception if you get denied.

To do so, your doctor must support the request by giving a statement. After the application gets approval, your plan will pay for the drug without prior authorization.

Although each plan may have a different process, always check with your policy for specific rules.

The process of getting prior authorization can take days. Although, you should call your local pharmacy within a week to see if your request was approved. In some cases, authorization is either denied or delayed. If this happens, contact your insurance provider and ask them why.

The information can be overwhelming, and things are continually changing. Also, agents can help you with getting a Prior Authorization Form. At MedicareFAQ, we love helping current and future beneficiaries. Our agents can answer any additional questions or concerns you may have. We’re here for you!

Our goal is to find the most comprehensive coverage for your medical needs at the best price. We will do all the hard stuff, like comparing rates in your area. To talk to an agent today, call the toll-free number or fill out our online rate form.