The short answer
Prior authorization is approval your plan requires before it will cover certain drugs. You or your prescriber must get it, and your prescriber may need to show the drug is medically necessary and that you meet the plan's requirements for it.
Your prescription is on your plan's list. Your pharmacy still cannot fill it. Something has been added on top of coverage, and it has a name, a process, and a documented way around it.
What is prior authorization for medication?
Prior authorization is approval, based on your plan's own requirements, that you or your prescriber must get before the plan will cover certain drugs. Your prescriber may need to show the drug is medically necessary and that you meet the plan's requirements for it.
Note where the rule sits. The drug can be fully covered and still carry this. Being on the list and being available to you are two different states.
One thing may soften the first weeks. When your drug coverage begins, you may get a transition fill: a one-time 30-day supply of a drug you have been taking that your plan either does not cover or requires prior authorization or step therapy for.
It is a bridge rather than a solution, and the clock on the real answer starts anyway.
Why did my plan require it?
Plans use prior authorization as one of a small set of rules, alongside step therapy, quantity limits, and medication safety checks such as drug management programs for opioid pain medications. Your plan may use some of these rules, all of them, or none of them at all.
There is a second reason that surprises people, and it is not about cost at all.
Plans may use prior authorization when they cover a drug for certain medical conditions and not others. When that happens, the plan keeps other drugs on its list for the other conditions the drug is used to treat.
So the question your plan is asking may not be whether you need medicine. It may be whether you are one of the conditions this particular drug is covered for.
That distinction changes what your prescriber has to write, which is the subject of the next section.
How do I request it?
You or your prescriber contacts the plan and asks for an exception to the prior authorization requirement. Your prescriber then supplies a supporting statement, and that statement is the substance of the request rather than a formality attached to it.
Three people are allowed to file. You, your prescriber, or your representative may request a standard or an expedited coverage determination from the plan.
How you file depends on what you are asking for. A standard or expedited request for a benefit may be made verbally or in writing. A standard request for payment must be in writing, unless your plan accepts verbal ones.
Here is what the statement must say.
| What your prescriber must state | Why it works |
|---|---|
| This drug is medically necessary despite the requirement | It answers the plan's own test |
| You will have negative health effects taking a different drug | It rules out the alternatives |
| A different drug would be less effective | It rules them out on outcome |
Any one of those three carries the request. They are alternatives rather than a checklist.
A waiver is filed under another name. This is our reading rather than a rule CMS states, and three of its facts produce it.
A formulary exception is the request used to waive a utilization management requirement on a drug already on the list. An exception request is a type of coverage determination. And a coverage determination expressly includes a decision on whether you have satisfied a prior authorization requirement.
So the way out of prior authorization is a request that does not carry its name. Those three facts are CMS's. Putting them together is ours.
How long does a drug prior authorization take?
Once your plan has your prescriber's supporting statement, it must give written notice of its decision within 72 hours for a standard request, or 24 hours for an expedited one. The first notice may be verbal, so long as a written one follows within 3 calendar days.
The words at the front of that sentence carry the whole thing. For a request involving an exception, the timeframes do not begin until the plan receives the statement from your prescriber.
A request filed on Monday with no statement behind it is not a request your plan is running late on. Nothing is late, because nothing has started.
So when nothing has moved, what is missing sits at your prescriber's office rather than at the plan. This publication's article on requesting a drug exception sets out the full clock.
What if it is denied?
The refusal is also the instruction sheet. If your plan's coverage determination is unfavourable, the decision itself contains the information you need to file a request for redetermination with the plan. Redetermination is the formal name for the first level of appeal, and it goes back to your own plan rather than to Medicare.
That is worth knowing before the letter arrives, because a refusal reads like an ending and is actually a set of directions.
You are not the only person who can act on it either. You, your prescriber, or your representative can appeal the decision by asking the plan for a standard or an expedited redetermination.
Before you start, Medicare's own instruction is to ask your provider or supplier for any information that may help your case.
How do I appeal a prior authorization denial?
You file a redetermination request with your plan, and you have 65 calendar days from the date of the notice to do it. That is the date printed on the letter, not the day it reached you. You, your prescriber, or your representative may file it.
How you file depends on which speed you need. An expedited request may be made verbally or in writing. A standard request must be in writing, unless your plan accepts verbal requests, which your plan or your Evidence of Coverage will confirm.
Your plan must then decide as quickly as your health requires, and no later than 7 calendar days for a standard request or 72 hours for an expedited one.
If that goes against you, the ladder continues. There are five levels in all, running from your plan's own redetermination through an Independent Review Entity, the Office of Medicare Hearings and Appeals, the Medicare Appeals Council, and finally a Federal district court.
The pattern from the first refusal repeats. If the redetermination is unfavourable, that decision contains what you need to file for a reconsideration by the Independent Review Entity, which is the first review by someone outside your plan.
At every level you get a decision letter telling you how to reach the next one.
What this means for you
Prior authorization is approval your plan wants before it covers a drug, and a drug can be fully on the list and still carry it. Being covered and being available are not the same thing, and that is the distinction the whole of this page turns on.
The reason may not be money. Plans also use it when a drug is covered for some conditions and not others, and that changes what your prescriber has to argue.
The way out is a formulary exception, which is the request that waives this kind of requirement even though its name says nothing about prior authorization.
The clock does not start when you file. It starts when your plan receives your prescriber's statement, and then runs 72 hours, or 24 if expedited.
If you are refused, the letter tells you what to do and you have 65 calendar days from the date on it. For the full request and appeal process, read this publication's article on requesting a drug exception. For being made to try another drug first, read the article on step therapy.
FAQ
Does prior authorization mean my drug is not covered?
No, and the distinction matters. Prior authorization is approval your plan requires before it will cover certain drugs, which means the drug can be fully on your plan's list of covered drugs and still carry the requirement.
Being covered and being available to you today are two separate states. Your prescriber may need to show that the drug is medically necessary and that you meet the plan's specific requirements for it.
There is also a case where the plan covers the drug for some medical conditions and not others, and in that situation the plan will keep other drugs on its list for the other conditions the drug is used to treat.
Can I get my medicine while the request is pending?
Possibly, if this is the start of your coverage. Medicare states that when your drug coverage begins you may get a transition fill, which is a one-time 30-day supply of a drug you have been taking that your plan either does not cover or requires prior authorization or step therapy for.
That is a bridge rather than a solution, and it does not pause or extend anything: the request still has to be made and decided on its own timetable. Outside that opening period, what you can get while waiting is a question for your plan and your pharmacy rather than something Medicare publishes a general rule about.
Who asks for the exception, me or my doctor?
Either, and a representative can too. You or your prescriber can contact the plan to ask for an exception to the prior authorization requirement. But only your prescriber can supply the supporting statement, and that statement is what the decision actually turns on.
It must explain their belief that it is medically necessary for you to be on the drug even though you do not meet the plan's requirements, or that you would have negative health effects on a different drug, or that a different drug would be less effective.
Any one of those three carries the request; they are alternatives rather than a checklist to complete.
Why is my plan taking so long to decide?
Most often because the clock has not started. CMS states that for requests involving exceptions the adjudication timeframes do not begin until the plan receives the supporting statement from your prescriber.
Once it has that, the plan must give written notice within 72 hours for a standard request or 24 hours for an expedited one, and it may give the first notice verbally provided a written one is posted within 3 calendar days.
So a request that has been sitting for a week may not be late at all. Where nothing appears to be moving, what has not arrived yet is the statement from your prescriber.
How long do I have to appeal a refusal?
A redetermination request must be filed with your plan within 65 calendar days from the date of the notice of the coverage determination. Read that as the date printed on the letter rather than the day it arrived, because an envelope that sat unopened has been spending your window. You, your prescriber, or your representative may file it.
An expedited request can be made verbally or in writing, while a standard request must be in writing unless your plan accepts verbal ones, which your Evidence of Coverage will tell you. The plan must then decide no later than 7 calendar days for a standard request, or 72 hours for an expedited one.
What happens after the first appeal?
There are five levels of appeal in a Medicare drug plan, and if you disagree with the decision at any level you can usually move to the next.
The first is the redetermination by your own plan. The second is a reconsideration by an Independent Review Entity, which is not your plan and is the point at which someone outside the company looks at it.
The third is a decision by the Office of Medicare Hearings and Appeals, the fourth a review by the Medicare Appeals Council, and the fifth judicial review in a Federal district court. At each level you receive a decision letter with instructions for moving to the next, so the route forward is always written down for you.
