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  • Prior Authorization and Pre-Claim Review Initiatives | CMS
    Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules For more information, see our Prior Authorization and Pre-Claim Review Program stats in the “Downloads” section below
  • Forms | CMS - Centers for Medicare Medicaid Services
    The Request for a Medicare Prescription Drug Redetermination and Request for Reconsideration of Medicare Prescription Drug Denial Forms are available for use beginning 01 01 2025
  • Prior Authorization for Certain Hospital Outpatient Department (OPD . . .
    CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care – while protecting the Medicare Trust Fund from improper payments and, at the same time, keeping the medical necessity documentation requirements unchanged for providers
  • Medicare Advantage Prior Authorization and Step Therapy for Part B Drugs
    Existing CMS guidance discouraged plans from using prior authorization for Part B drugs and prohibited step therapy As a result, Medicare Advantage plans had little ability to negotiate on behalf of beneficiaries to get better value for Part B therapies
  • REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION
    request an exception to the requirement that I try another drug before I get the drug my doctor prescribed (formulary exception) * request prior authorization for the drug my doctor has prescribed
  • Prior Authorization Process for Certain Hospital Outpatient Department . . .
    The prior authorization program for certain hospital OPD services ensures that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in the volume of covered services and improper payments
  • Medicare Part D Coverage Determination Request Form
    Medicare non-covered drugs, including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations) Biotech or other specialty drugs for which drug-specific forms are required
  • Coverage Determinations | CMS
    A decision whether an enrollee has, or has not, satisfied a prior authorization or other utilization management requirement How to Request a Coverage Determination


















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