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What is prior authorization for Medicare?

An older woman speaks with her healthcare professional discussing Medicare's prior authorization process

Prior authorization is the approval process required for certain prescriptions, healthcare treatments, services or supplies to be covered under your Medicare or prescription drug plan. While not all prescriptions, treatments and services need prior authorization, here’s what you need to know about the prior authorization process and Medicare. 

How the Prior Authorization Process Works

For the most part, you shouldn’t have to worry much about the prior authorization process, as your doctor’s office and health insurance company will handle it. Your insurance company will notify you if coverage of the prescription, medical device or service has been approved or denied. 

Depending on the type of prior authorization request, the process can take anywhere from one day to one month. This is why it is important for your doctor to submit prior authorization forms for Medicare and requests earlier rather than later. 

Benefits Of Prior Authorization

While the process of prior authorization can seem long and drawn out, there are certain benefits of prior authorization with Medicare, including:

  • It can help lower the cost of expensive prescriptions by presenting a lower cost alternative that could be equally as effective
  • It is designed to help you from being prescribed medications you may not need or prescriptions that could have adverse effects when taken with your other medications
  • It is a way for your health insurance company to manage costs for otherwise expensive medications

Drawbacks to Prior Authorization

There are several benefits to prior authorization, however, it does include a few drawbacks, including:

  • Delayed treatment process
  • You may end up responsible for emergency medical costs depending on the terms of your health plan
  • Delayed medications

Which services and plans require prior authorization?

Requirement for prior authorization is unique to each Medicare plan. Services covered under Medicare Part A and Part B often do not require prior authorization. While each plan varies, Medicare Part D plans usually need prior authorization for coverage on specific drugs. Medicare Advantage plans may require prior authorization to obtain out-of-network, specialist and emergency care. 

Since the requirement for prior authorization varies between each plan, you’ll want to contact your insurer directly to confirm your coverage. 

What to Do if You’re Prior Authorization is Rejected

If your prior authorization is rejected, you have a couple of options. If covering the full out-of-pocket cost of the treatment or prescription is unrealistic, your doctor may be able to recommend alternative options for you. You also have the option to submit an appeal if you believe your request was incorrectly denied. There is a chance of clerical error and you’ll likely have success if your doctor deems your treatment medically necessary. 

Find the Medicare Plan That Fits Your Needs with SelectQuote 

There’s a lot to keep track of when it comes to Medicare, but you don’t have to do it on your own. At SelectQuote, we’ll help you understand the ins and outs of your Medicare coverage to ensure you have all the benefits available to you.

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