Medicare Part D Prior Authorization

What is Prior Authorization?

Prior authorization is a coverage management tool used by Medicare Part D plans. For certain drugs - typically expensive brand-name medications, specialty drugs, or drugs with high abuse potential - the plan requires your doctor to submit clinical information demonstrating that the drug is medically necessary before it will be covered.

Which Drugs Require Prior Authorization?

Common categories of drugs that often require prior authorization:

• Specialty drugs (biologics, cancer medications, MS drugs)
• Brand-name drugs when generics are available
• Drugs with high potential for misuse (certain opioids, sleep aids)
• Drugs that are typically second-line treatments
• High-cost drugs where the plan wants to confirm medical necessity

How to Get Prior Authorization

The prior authorization process typically works as follows:

• Your doctor submits a PA request to your Part D plan with clinical documentation
• The plan reviews the request (typically within 72 hours; 24 hours for urgent requests)
• The plan approves, denies, or requests additional information
• If approved, your prescription is covered per your plan's normal cost-sharing
• If denied, you have the right to appeal

What to do if Prior Authorization is Denied

If your PA request is denied, you have several options:

• Request a formulary exception - ask the plan to cover the drug without PA requirements
• File an appeal - you have the right to a formal review of the denial
• Ask your doctor about covered alternatives in the same drug class
• Request an expedited appeal if you need the drug urgently
• Contact your State Health Insurance Assistance Program (SHIP) for free help navigating the appeals process

Frequently Asked Questions

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