Medicare, Medicaid and the Prior Authorization Process

Medicare, Medicaid and the Prior Authorization Process

March 16, 2017  |  Ryan Druseikis

One of our objectives at CoverMyMeds is to make it as easy as possible to submit the correct prior authorization (PA) request for your patients.

We know there can be confusion about the difference between the three types of coverage (commercial, Medicare and Medicaid). You may have questions around how these programs affect prescription coverage and what that means for completing PA requests (the good news is, CoverMyMeds streamlines PA for Medicare and Medicaid, but more on that later). In this blog, we address questions like these and help to clear up any confusion around them.

What is Medicare?

Medicare is a government insurance program that becomes available to everyone at age 65, as well as for those meeting certain disability criteria. The four most common parts of Medicare are Part A (hospital), Part B (medical), Medicare Advantage and Part D (medications).1

Medicare Part D will cover most medications; however, Part B could be used to cover some as well. Generally, Part B will only be used to cover medications if they are being administered in conjunction with a procedure or with the use of durable medical equipment (DME). Often, the managing plan will have a specific PA request available to complete, detailing the specifics of the use/administering of the medication in question and whether it could be covered by either Part B or D.

What is Medicaid?

Medicaid is an insurance program funded mutually by federal and state governments.2 A patient assisted by Medicaid could have one of two types of plans: Managed Medicaid or State Medicaid.

Managed Medicaid plans are private enterprises that provide health benefits for individuals on the Medicaid program and are compensated on a per-person rate for fulfilling the patient’s coverage. State Medicaid plans are administered directly by the government of the state in which the patient resides. Because each state is responsible for its own Medicaid program, the eligibility can vary from one state to another.

Like Medicare plans, each Medicaid plan will have its own unique request form to complete, so it is important to find the correct one for the patient.

Is the process for completing PA requests for Medicare and Medicaid different from commercial plans?

The CoverMyMeds process for completing a Medicare or Medicaid PA request will look exactly the same from the provider perspective as completing a commercial request. If starting a request from scratch, you will be able to find the correct PA request form by using the patient’s RxBIN, RxPCN and RxGroup numbers from the front or back of the patient insurance card, or by reaching out to the pharmacy that ran the claim for the medication. Once a PA request has been selected, you will be able to complete the clinical questions and send the request to the plan for a final review and determination.

Just like for any commercial plan, CoverMyMeds works for any plan under Medicare Part D and Medicaid. Many of these plans have also transitioned to an electronic prior authorization (ePA) format, meaning you will receive an electronic determination, often in real-time. Plans that have ePA capabilities further decrease administrative waste and streamline the process.

If you have any questions about determining what type of coverage your patient has, or about the CoverMyMeds ePA solution, call 866-452-5017 or use the chat feature at to talk to a live expert. Our service is secure and HIPAA compliant, and will always be free to use for providers and pharmacies.



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