Prior authorizations can feel like a bad April Fool’s Day prank.

When you think you are getting the medication that can help your problem, your insurance has other ideas—prior authorization required. You ask how much and nearly pass out. Now, your doctor is left dealing with paperwork as you wait through the delay with frustration. You wonder if the approval process is just a cruel trick. The only difference? This “prank” isn’t funny. It can impact your health and well-being.

Understanding Prior Authorization (PA): What You Need to Know

If you have ever had a prescription or medical service delayed because it needed “prior authorization,” you are not alone. Prior authorization (PA) is a common process in healthcare. When you and your doctor know you need your medication right away, it can be very frustrating. Understanding how PA works can help you navigate the system more smoothly and ensure you get the care you need without unnecessary delays.

What is Prior Authorization (PA)?

Prior authorization is a requirement of your insurance company. Certain medications, treatments, or medical services must be approved before they are covered. Essentially, you doctor must provide information to your insurance company explaining why a specific treatment is necessary.

Why Do Insurance Companies Require PA?

Insurance companies utilize the prior authorization process to:

When is PA Required?

You may need prior authorization for:

How to Handle a PA Request

If your doctor prescribes a medication or treatment that requires PA, follow these steps:

1. Your Doctor’s Office Submits a Request – Your healthcare provider will send the necessary paperwork to your insurance company.
2. Insurance Review – The insurance company evaluates the request. This may take days or weeks.
3. Approval or Denial – If approved, you can proceed with the treatment. If denied, you have the right to appeal.

What to Do If Your PA is Denied

If your PA request is denied:

Tips for Avoiding PA Delays

Some Final Thoughts

Prior authorization can be frustrating. It is an important aspect of how insurance companies manage healthcare costs. By understanding the process and staying proactive, you can avoid unnecessary delays and ensure you receive the medications and treatments you need.

If you’ve had an experience with prior authorization (I shared a few of mine above), share your story or tips in the comments below!

Who cares about March Madness when something even more exciting started in January – Medicare Part D changes.

Medicare is like a magical land of benefits. Once you turn the magical age of 65, as well as younger individuals with disabilities or End-Stage Kidney Disease (ESKD), golden gates swing open. You can get the senior discount at your favorite restaurant. But you are also bombarded with AARP flyers. In this magical land, make sure you stop by the Qualifying Quilt store. Here, you will find aisles of options called the Parts of Medicare to create your health coverage quilt. Each of the Parts of Medicare serve a unique purpose.

The Parts of Medicare

Medicare Part A: covers hospital stays and some skilled nursing care – it’s like a cozy blanket when you need TLC.
 
Medicare Part B: focuses on outpatient care, doctor visits, and preventative services – it’s your sidekick for important check-ups.
 
Medicare Part C: also known as Medicare Advantage, this offers a mix of Parts A and B, and sometimes Part D, along with added benefits – it’s the buffet of Medicare healthcare.
 
Medicare Part D: the star for prescription drugs, ensuring you don’t break the bank for lifesaving medications.
 
So, Medicare is a colorful quilt of different parts working together for your health needs.
 
Now, let’s highlight the updates that the Inflation Reduction Act made in making the management of prescription drug costs easier. With a new $2000 Maximum Out-of-Pocket (MOOP) limit and three straightforward phases, it’s looking more manageable this year.

New Medicare Part D Annual Maximum Out-of-Pocket Limit for 2025

Starting in 2025, you’ll have a firm grip on your prescription drug expenses. Say hello to your new best friend: the $2000 Maximum Out-of-Pocket limit (MOOP)! This means that once you hit that magical number, your plan covers the costs of all those essential meds for the rest of the year! Remember, your monthly premium still applies outside the MOOP limit, but it’s exciting news!
 
Say goodbye to the uncertainty of past Part D plans, where costs felt like a rollercoaster ride! With the new changes, you can have a clearer picture of your prescription drug expenses, making it easier to budget and avoid surprise high out-of-pocket costs.

3 Simplified Phases of Medicare Part D

2025 is saying farewell to the bad ol’ “Coverage Gap” (aka Donut Hole)! Instead, Medicare Part D will simplify down to three easy-to-remember phases:
 
1. The Deductible Phase: 
Time to start things off! Beginning in January, your plan kicks in after you pay the first $590 of your prescription costs. It’s like a party cover charge—once you’re in, you’re in!
 
2. Initial Coverage Phase:
During this phase, you’ll be sharing the costs! You’ll only need to pay 25% of your covered drug costs until you reach that snazzy $2000 limit. It’s like having a partner in paying the costs!
 
3. Catastrophic Coverage Phase: 
And here comes the grand finale! Once you’ve hit that $2000 max out-of-pocket (MOOP) limit, you move into the “no more payments” zone! That’s right—you’ll typically pay nothing for covered drugs for the rest of the year. Your plan and Medicare take over, and you can relax knowing you’re covered!

Let’s show you how James is affected by these changes.

Understanding the 2025 Medicare Part D Plan

James has two costly prescriptions he fills each month, adding up to a hefty total of $1,440. Here’s how his Medicare Part D coverage works throughout 2025.
 
January:
James heads to the pharmacy to pick up his two medications as the year begins. The total comes to $1,440, but first, he needs to meet his $590 deductible. After that, James has $850 left to cover. Since he only pays 25% of the remaining cost, his out-of-pocket expense for January is $212.50 + $590 = $802.50.
 
February: 
In February, James had already met his deductible, so now he pays 25% of the cost of his drugs, which comes to $360.
 
March to December:
James continues this pattern each month, paying 25% of his medication costs ($360). By June, he reaches the maximum out-of-pocket (MOOP) limit of $2,000. This milestone is a big relief for James because it means he won’t have to pay anything for his covered prescriptions for the rest of the year. However, he still needs to keep up with his monthly premium (the average monthly premium for Medicare Part D plans is around $46.50).

So, if you just turned the magical age of 65 and you’re on the lookout for a shiny Part D drug plan or are just curious about these fantastic changes, check out www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227). You can also reach out to MedsCheck and our pharmacist can direct you to the right organizations.