How is prior authorization different from other coverage decisions?
Your plan makes a coverage decision on requests for a service or drug to be covered. These requests can be made at any point in your care. Request a coverage decision
Prior authorization is a type of coverage decision. This is when approval for coverage is required before you receive certain services or drugs. If you receive care or fill a prescription before you get an approval, you may be responsible for the full cost.
How does prior authorization work with Aetna Medicare plans?
The prior authorization process helps you get quality care that’s covered by your plan. When making a decision, Aetna follows specific guidelines, timelines and rights that are set by the Centers for Medicare and Medicaid Services (CMS).
What services or drugs require prior authorization?
Not all services and drugs require prior authorization. In most cases, your provider will let you know when this is needed. You can search the lists below to see what may require prior authorization, so you know what to expect.
Medical service requests
Applies to inpatient hospital stays, skilled nursing facility care, outpatient services, durable medical equipment (DME) and specialist visits as required by your plan.
View medical services that need prior authorization
View a list of Part B drugs you typically get in a medical setting
Prescription drug requests (Part D)
Applies to some prescription drugs on your plan’s formulary (drug list). Your provider or pharmacist will let you know if prior authorization is required before a prescription is filled.
To find out which prescription drugs need prior authorization:
Check the formulary (drug list)
Frequently asked questions (FAQs)
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In most cases, your provider will handle any prior authorization requests for services or drugs when needed. There are some cases where you have the option to submit requests yourself:
When you or someone you give permission to, would like to submit a prescription drug prior authorization request. Request a coverage decision or prior authorization for a prescription drug.
When you’re planning to receive medical services from a provider out of network. In this case, call the number on your member ID to begin the process.
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Depending on the details of the request and your plan, here is what you can usually expect. If waiting the standard amount of time for a decision places you at risk, you or your provider can ask for a faster (expedited) review.
Standard process time
Medical service requests: Within 7 calendar daysPrescription drugs request (Part B and Part D): Within 72 hours
Expedited process time
Medical service requests: Within 72 hoursPrescription drugs request (Part B and Part D): Within 24 hours
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We understand you may not agree with our decision. If so, you have options:
Talk with your provider. They’ll have a copy of the decision reason from us and can discuss next steps with you.
Request a formal appeal. You, your provider or someone you give permission to has the right to appeal. This means asking us to revisit our decision.
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You can fill out an Appointment of Representative (AOR) form. This gives a person you select permission to take action for you.
You can also complete a Protected Health Information form, too. This allows us to talk to someone you trust about your care.
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Some plans require a referral for specialist care. Referrals aren’t the same as prior authorization, but you may need both for coverage. Check your plan documents to see if this is needed. If so, talk to your provider about getting a referral before prior authorization.