How Medicare Prior Authorization Works and Why It Is Necessary

Medicare Prior Authorization

Many expensive and non-routine procedures and prescriptions require Prior Authorization. Here's why.

Depending on what type of medical services you use, it may be necessary for you to obtain prior authorization (PA) through your Medicare health plan before your benefits will pay out. Medicare prior authorization is a requirement that your doctor or health care provider get approval from your plan to provide a given service.

One reason that a prior authorization may be required is for the health care plan to confirm that a particular procedure, service, or item is medically necessary, and that the treatment being prescribed by the health care provider is appropriate for the enrollee’s condition.

Which Medicare Plans Require Prior Authorization?

If you are enrolled in Original Medicare (which is Medicare Part A and Part B), you won’t typically need to get a prior authorization. This is the case even if you are going to see a specialist, obtain care in a hospital, and/or receive care out of state.

It may, however, be required that you obtain prior authorization for some services, as well as for various items of durable medical equipment. Likewise, in some states, it may also be required that prior authorization is obtained before a Medicare enrollee can receive Medicare-covered home health care services.

Medicare Advantage plans (which are also often referred to as MAPD plans) will also usually require that a person get prior authorization before being covered for certain services. Although all Medicare Advantage plans can differ, it is typically the case that prior authorization is required for the coverage of out-of-network care, as well as for specialist visits, and non-emergency hospital care.

Medicare Prescription Medication Prior Authorization

As with other Medicare-covered services, it may also be necessary for you to get prior authorization before you are covered under Medicare Part D for some (or even all) of your prescription medications.

When your health care provider prescribes a particular medication for you, it is likely that you trust that it’s the right one for you. However, this is not necessarily always the case – which is why Medicare has prior authorization procedures in place.

So, similar to with other Medicare benefits, Medicare Part D prior authorization is a requirement that your doctor first obtain approval from your Medicare prescription drug plan in order to prescribe a certain medication to you.

Why Do Certain Prescription Medications Require a Prior Authorization?

Prior authorization is a technique that is used by health insurance plans that is oftentimes used for minimizing expenses. In this case, the insurance plan must first pre-approve the medication before it will pay out benefits.
With regard to medications, though, there are some other reasons why prior authorization may be required. For instance, in some cases, a particular drug might have dangerous side effects. It may also be harmful if it is combined with other medication(s) that you are already taking.

In addition, there are some instances where a particular drug might be mis-used or even abused. With that in mind, your Medicare health plan may require prior authorization in order to better ensure that various drugs are used by enrollees in the proper manner.

What To Do If Prior Authorization is Required for Your Medication(s)

If it is necessary that a medication you’ve been prescribed requires prior authorization, then it is recommended that you and / or your pharmacist talk with your health care provider about other drugs that do not require prior authorization that could be substituted.
If there are none, then you should contact your Medicare health plan directly for more information on how to begin the prior authorization process, and about how long it may take for the plan to make its approval decision.

Need More Information on Medicare Prior Authorization?

In order to obtain more information on Medicare’s prior authorization process, you can contact your particular plan directly. The phone number for your plan will typically be listed on the back of your health care identification card.