What if the drug you need requires "prior authorization?":QuickMedicareSupplement.com

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What if the drug you need requires "prior authorization?"

What if the drug you need requires "prior authorization?"

If the pharmacist tells you that the drug requires prior authorization (PA), you should make contact with your plan to find out about the PA requirement. Then, ask your doctor if you meet this condition. In many cases, the plan will have a PA form that your doctor can complete and put forward to the plan. You should ask your plan if it has a form for your doctor to make use of. Since a request for PA is a coverage determination request, when you or your doctor submit proof to the plan to show that you meet the PA requirement, the plan should give notice to 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." If the plan decides you don't meet the PA requirement, you can appeal.

In a few cases, your doctor may think you can't meet the PA requirement, but that you still need the drug. In those cases, you can request the plan for an "exception" not to apply the PA requirement. Once more, you would have the right to appeal if the plan denies this request.

Each time you ask for any type of exception, your doctor will need to provide a statement to the plan to support this request. You must make contact with your plan to find out what information the plan wants. If the plan approves your exception request, it's good for at least the remainder of the plan year, as long as you stay enrolled in the plan, your doctor continues prescribing the drug, and the drug continues to be safe and effective for treating your sickness or condition.

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