Prior Authorizations for Medicare Part D Drugs Explained

If you're taking a very expensive brand name drug, there's a lot of bad news, right? Besides the price. If your insurance company does cover it, so you looked on the list and, oh yeah, they cover my drug. You're still not in the clear because they might make you go through some hoops to actually get that drug. So one of the hoops is called prior authorization. And that means your doctor says you need it, but the insurance company goes, I don't know if you really need it. So convince me that she needs this expensive drug. So your doctor plays this game trying to get approval from your Medicare Part D drug insurance company to approve your drug. And yes, this can take a little while. So you're frustrated, but you got through it and you finally got your approval and you got your letter and it says you're approved. Read that letter. That prior authorization approval letter might say you're only approved for six months. Now, typically they approve you for a whole calendar year. So read the letter. Now, if you want to change your drug plan and go to another company, or if you move and you have to change it, the other insurance company is going to make you go back through that whole rigmarole because that other insurance company also doesn't want to pay for your expensive brand name drugs. So it's going to make your doctor play the game with the new insurance company. It's just how it is. Now there's news for 2025 because biosimilar drugs, a new term for most people, they're not generic drugs. They're similar. They're similar, but they're not. So a generic drug is exactly the same as a brand name drug. Biosimilar drugs are cheaper than the brand name drug, but they're not identical and they're not as cheap as generic. So for example, if you're taking Humira, Humira is one of the most popular and one of the most expensive drugs in the country. I think nobody's covering it for 2025. So they're not going to cover the brand name Humira, but there are three different bio-identical drugs, biologic drugs. And for the life of me, I can't remember them, but they're, you know, with X's and Y's and long, long names. You can Google it. So your doctor has to prescribe you one of those drugs. Then you have to ask the insurance company for authorization and they can say, nah, no. So then your doctor has to prescribe the other one and your insurance company will say, okay, you know, you have to get to play this game. And in 2025, the government, Medicare, authorized all the drug companies, your standalone drug company and your Medicare Advantage companies with the drug benefit to just switch you out. That if you were getting a drug and now there is a biological drug, a bio-identical drug, biosimilar drug that they can just switch you. And they can say, we no longer cover the brand name drug. Now we only cover the biosimilar. So that's coming in 2025. And now, you know, you're ahead of the curve of how prior authorization works. And it's not for one insurance company. It's for all insurance companies that offer a Medicare Part D drug benefit. So ideally you're not taking a drug that requires prior authorization from your insurance company. But if you do, you know, the rigmarole, that's what we do at the Medicare family. We've been helping people for 45 years. My family has been doing this for 45 years. We have thousands of clients all across the country. So if you need help, give us a call, the Medicare family, or go online and book your free appointment at themedicarefamily.com. Hope this helps. If you like this video, you might really like this video, check it out. And we'd appreciate if you subscribe to our channel. So you never miss a great video. We put out one every week, check in the description below this video for a link to our cheat sheet on social security and Medicare. And you can also give us a comment. If you have a specific question, always feel free to call us or email us at the Medicare family.