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What do I do if the medication I use requires "prior authorization?"


If your pharmacist tells you that one of your Medicare Part D prescription drugs requires prior authorization (PA), you should contact your Medicare Part D plan to find out about the PA requirement and whether your plan has a PA form for that your doctor would complete and submit to the Part D plan.

To learn more, you can telephone your plan's Member Service department using the toll-free number found on your Member ID card or most of your plan's printed information.

Be sure to also ask your doctor if your medical needs meet this Prior Authorization requirement.

In some cases, your doctor may think you cannot meet the PA requirement, but that you still need the drug. In those cases, you can ask the Medicare plan for an "exception" not to apply the PA requirement.

Since a request for PA exemption is a formulary exception request (or a Coverage Determination request), when your doctor submits evidence to the plan showing that you should be excluded from the PA requirement, the Medicare plan must notify you of its decision no later than 72 hours from the time it received your request or 24 hours from the time it received your request if your case is "expedited."

Your Medicare Part D plan will not automatically grant every Formulary Exception request.  But, if your Medicare plan decides you do not meet the PA requirement, you can appeal the Medicare plan's negative decision.

You can read more about appealing your Medicare Part D plan's negative decision here:
https://q1medicare.com/PartD-HowToDrgExceptionAppealComplaint.php

Whenever you ask for any type of exception, your doctor will need to provide a statement to the plan to support this formulary exception request and you should contact your Medicare plan to find out what information the plan needs to make decision.

If your Medicare prescription drug plan approves your exception request, the PA exemption is valid for the remainder of the plan year, as long as you remain enrolled in the plan, your doctor continues prescribing the drug, and the drug continues to be safe and effective for treating your illness or condition.

It is possible to ask your Medicare plan to make a PA determination before the start of your Medicare plan year (January 1st), but this may depend on your particular Medicare plan and you can contact your plan's Member Services for more information about getting a PA for the next year (the toll-free number is on your Member ID card).

(Source: Includes information from U.S. Department of Health & Human Services)





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