Some medications are carefully monitored by Medicare Part D plans to ensure your safety and your plan may require that you receive prior approval or "prior authorization" before your prescription will be covered by that plan.
Prior Authorization is one of the "usage management" tools available to a Medicare Part D plan to help control drug usage (and reduce plan costs). Other usage management restrictions
include Quantity Limits
and Step Therapy
The Centers for Medicare and Medicaid (CMS) defines "Prior Authorization" as:
approval from an insurance plan [Medicare Part D plan or Medicare Advantage plan] before you get care or fill a
prescription. In many instances, your doctor or health care provider
must first contact the plan and show there is a medically-necessary
reason why you must use that particular drug for it to be covered.
you fill your prescription without prior authorization, your Medicare
plan probably will not
pay for the coverage and you will be charged
full-retail price for the drug.
Does your Medicare Part D plan require Prior Authorization of your formulary drug?
If you are not sure about which
of your medications require a prior
authorization, you can refer to your Medicare plan's formulary -- or call
your plan's Member Services department (the toll-free number is on your
Member ID card) -- or you use our Drug Finder
tool (found at Q1Rx.com
) to check for any usage management restrictions on your prescriptions.
In our Q1Medicare Drug Finder, enter
your medication, choose the strength if there are multiple varieties,
and you can choose your Medicare Part D plan (or two plans if you wish to
compare), otherwise all Part D plans in your area will be shown.
The Drug Finder search results will show a “P
” for medications that require a
Submitting a request for Prior Authorization
If your medication has a prior authorization (PA) restriction, then prior authorization forms can be ordered from
your Medicare Part D plan member services department or downloaded from your Part D plan’s website.
Once you have the PA form, your
physician can usually complete the form with an explanation of the medical necessity and fax the forms directly to your Part D plan. You may wish to ask your plan for an "expedited" or faster review based on your medical condition or need.
Please note, we have heard that, for certain prescriptions, some
Medicare Part D plans require a prior authorization form be filed for each
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