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Prior authorization may be required, particularly if you have Medicare Advantage rather than traditional Medicare with a stand alone Part D prescription drug plan. Administratively burdensome for your physician and nail-biting for you, prior authorization is more likely to be required if the medicine is new, expensive or part of a complex therapy.

How consistent is this with FDA indications? A study published in the Journal of the American Medical Association Health Forum on February 24, 2023, sought to find out.

Fortunately, among the 109 drugs eligible for Part D coverage, 104 were on the formulary (list of covered medications) of at least one insurer – hopefully yours.

Unfortunately, two-thirds required prior authorization. In 39% of the cases, this required submitting medical information. There was substantial variation in the total number of requirements, with Kaiser Permanente requiring the least (8 drugs) and Humana the most (187).

40% of the requirements were more restrictive than the FDA-approved labeling with some having shorter coverage than the full plan year. For some, authorization was conditioned on previous or coadministration of certain other therapies.

If prior authorization is required, check this out. Your insurer should not require anything more restrictive than the FDA.

 

Elder law attorney, Terry Garrett, CELA, is a member of the National Academy of Elder Law Attorneys and is an Approved Guardianship Attorney. She assists people in elder law, estate and special needs planning, guardianship and settling estates. She graduated with honors from Cornell University. She was on the Dean’s List at Wharton Business School. She earned her J.D. at Columbia Law School, receiving the Parker Award and a Mellon Fellowship.

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