Prior Authorization
Prior authorization is approval you must get from your plan before certain services or drugs will be covered. Without it, the plan may not pay for the service.
Understanding Prior Authorization
Prior authorization (prior auth) is approval you must get from your Medicare plan before certain services, treatments, or medications will be covered. Without approval, the plan may not pay.
Plans use prior authorization to ensure that the requested service is medically necessary and that less expensive alternatives have been tried when appropriate (called step therapy).
The prior authorization process typically involves your doctor submitting documentation to the plan. Standard decisions must be made within 72 hours (24 hours for urgent requests).
If prior authorization is denied, you have the right to appeal. Your doctor can request an expedited appeal if waiting would jeopardize your health. Many denials are overturned on appeal.
Related Terms
Formulary
A formulary is a list of prescription drugs covered by a Medicare drug plan. Drugs are organized into tiers, with different cost-sharing for each tier.
Medicare Advantage
Medicare Advantage (Part C) is an alternative to Original Medicare offered by private insurance companies approved by Medicare. These plans include Part A, Part B, and usually Part D coverage in one plan.
Part D
Medicare Part D is prescription drug coverage. You can get it through a standalone Prescription Drug Plan (PDP) or through a Medicare Advantage plan that includes drug coverage.
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