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Medicare Part D prior authorization requirements examined

Case Management Weekly, February 22, 2006

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In a recent article, The New York Times examined how some physicians and pharmacists maintain that many medications covered by Medicare prescription drug plans are not readily available to beneficiaries because of prior authorization requirements. Medicare prescription drug plans require prior authorization--or pre-approval from the plan sponsors--as a prerequisite for coverage of many medications.

Medicare prescription drug plan sponsors argue that prior authorization requirements prevent unnecessary prescriptions and encourage the use of less-expensive medications. However, some physicians and pharmacists maintain that prior authorization requirements used by Medicare prescription drug plans are excessive and could prevent access to some medications for beneficiaries.

According to the Times, a Medicare prescription drug plan might have 25 or 30 forms for prior authorization for different medications. The forms often require laboratory test results, all office notes, and other data to demonstrate need for medications.

Source: California Healthline

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