Prescription Drugs
Prior Authorization
Quick answer
Prior authorization is a plan requirement that your doctor get approval before a specific drug or service is covered. It's used to confirm medical necessity and steer to lower-cost alternatives.
Plain-English definition
PA requests are typically processed within 24-72 hours; expedited requests are faster.
Why it matters
PA can delay care — knowing the process in advance helps.
A simple example
Your MRI requires PA. Your doctor's office submits the request and the plan approves it.
Common mistakes & misconceptions
Related terms
Step Therapy
Step therapy requires you to try a lower-cost drug first before the plan covers a more expensive alternative for the same condition.
Quantity Limit
A quantity limit caps how much of a drug the plan will cover in a given period, based on FDA-approved dosing.
Coverage Determination
A coverage determination is the plan's formal decision about whether a drug is covered, how much you'll pay, and any requirements like prior authorization.
Appeal
An appeal is your formal request to change a coverage or payment decision made by Medicare, a Medicare Advantage plan, or a Part D plan. Medicare has five levels of appeal.
Frequently asked questions
Can I get an emergency exception?+
Yes — request an expedited decision.
Sources & references
📚 Where this information comes from
- Medicare.gov — official U.S. government site for people with Medicare ↗Primary source for benefits, enrollment periods, and plan comparison.
- CMS.gov — Centers for Medicare & Medicaid Services ↗Federal rulemaking, program updates, and official guidance.
- Social Security Administration — Medicare enrollment & premiums ↗Enrollment, premium withholding, and IRMAA determinations.
When you're ready, compare plans on your own terms
See Medicare Advantage plans from the insurance companies we represent, or walk the course with a licensed agent whenever you'd like a second set of eyes.
We help compare Medicare Advantage plans from the insurance companies we represent, and we don't offer every plan available in your area.
Medicare Caddies is an independent insurance agency. We are not affiliated with, endorsed by, or connected to the U.S. government, the federal Medicare program, or the Centers for Medicare & Medicaid Services (CMS). We help compare Medicare Advantage plans from the insurance companies we represent, and we don't offer every plan available in your area.