UNDERSTANDING PRIOR AUTHORIZATION IN MEDICARE PART D WHY CAN’T I JUST GET MY MEDICINE?!
ONE PLAN MAY APPROVE IT — ANOTHER MIGHT NOT
WHAT NEEDS TO BE ON THE FORM? • The correct diagnosis • A history of your condition or symptoms • Why other (cheaper) drugs won’t work • Follow the instructions closely
You may have heard about prior authorization in the news, or maybe you’ve run into it yourself. It’s when your Medicare plan says, “Hold on a minute … before we cover that, we need more info.” Over the past few years, prior authorization has become a big issue with Medicare Advantage plans. And now in 2025, we’re starting to see more problems with prescription drugs under Part D. Several clients called or emailed me this year about delays or denials in getting their medications. That’s new. So, let’s talk about what’s going on and what you can do about it. WHY IS THIS HAPPENING NOW? Because of the Inflation Reduction Act, your out-of-pocket drug costs will be capped at $2,000 . That’s great news for you, but it also means drug plans are now paying more. And when companies pay more, they ask more questions. That’s where prior authorization comes in.
One man told me he changed to a cheaper plan that saved him a few hundred dollars a year. But now, his expensive Tier 5 specialty drug needs prior authorization, and he can’t get it approved. He’s frustrated. But here’s the thing: I checked, and every plan in his area requires authorization for that medication. There was no way around it. Even some Tier 3 (preferred brand) and Tier 2 (generics) can require approval now. So, always check before switching plans. EVERY PLAN HAS ITS OWN FORMS AND PROCESS Another client said he waited two weeks for approval, only to find out his doctor sent the wrong form . That’s frustrating. Some forms are one page, others are nine pages long. You can find the right one by searching online for: “Part D prior authorization form for [Your Drug Plan Name]”
And yes, the form must be fully filled out or they’ll reject it.
HOW LONG DOES IT TAKE? • Standard requests must be answered in 72 hours. • Urgent requests can be handled within 24 hours. But remember, that clock doesn’t start until the form is fully submitted with all the correct info. WHAT YOU CAN DO TO HELP While your doctor is the one who submits the request, you can help make things go smoother: • Check your plan’s documents to see if your meds require prior authorization. • Don’t wait until the last minute — be proactive. • Print the right form and bring it to your doctor. • Watch your mail (or online account) for updates. • During Open Enrollment, shop around — but compare the pros and cons. Prior authorization can feel like a pain, but we need to deal with it more often now. And even though your doctor is in charge of the paperwork, you’re still part of the team. So, stay informed, stay ahead of it, and don’t hesitate to reach out if you need help. We're here to guide you every step of the way. Connect with a licensed insurance agent.
WHY DO DRUG PLANS WANT PRIOR AUTHORIZATION?
You can also call the plan directly — just be ready to wait on hold.
Here are the top three reasons:
WHO CAN SUBMIT THE REQUEST? • The doctor is the best person — they know why you need the medication. • You , the patient, can also submit it, with help from your doctor. • The pharmacist may be able to help, but can’t always do it alone. Example: A woman ran out of medicine and went to the pharmacy on a Sunday. She was shocked to learn she needed prior authorization. The pharmacist couldn’t help, and the doctor wasn’t available. That’s a tough spot.
• There’s a cheaper drug that works just as well. • The drug might be covered under Part A (hospital) or Part B (medical) instead of Part D. • The drug isn’t being used for what it’s usually approved for.
Other reasons might include:
• Medications that need extra monitoring. • Unusual doses or forms of a drug. • Controlled substances. • Drugs that could interact with others you’re taking.
2 • OmahaInsuranceSolutions.com
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