Prior authorization
What you need to know about: Prior authorizations
I’m concerned about the need to get prior authorizations. What do I need to know?
The MLC unions fought hard on this issue, and thanks to our strong advocacy, the vast majority of procedures will not require prior authorization under the Aetna Medicare Advantage PPO plan. For example, the Aetna Medicare Advantage PPO plan does not require prior authorization for many routine tests, like MRIs, CT scans, PET scans and much more, making this plan unique to the city. Emergency and many urgently needed services don’t require prior authorizations at all.
What procedures will require prior authorization?
- Acute hospital inpatient care (not ER)
- Long-term acute care, acute physical rehabilitation, skilled nursing facility, and home care services
- Durable medical equipment
- Part D medications
- Specialty medications, some of which are Part B medications
- Placement on an organ transplant list
- Substance abuse treatment
- Services that are cosmetic in nature (e.g., breast augmentation, removal of excessive skin/tummy tuck or eyelid surgery).
- Services/items that are not covered by Medicare
- Services that could be considered experimental and investigational in nature
- New-to-market drugs, therapies, procedures, services, and technologies covered by Medicare after the start date of the new plan, Sept. 1, 2023.
The MLC, City and Aetna will monitor usage and meet to determine whether future changes to this process are needed.
What procedures or services would not require prior authorization?
No prior authorization will be needed for the vast majority of services, including:
- MRIs
- CT scans
- PET scans
- sleep studies
- radiation therapy
- pain management
- diagnostic cardiology
These services typically require prior authorization in Medicare Advantage plans, but are not needed under the custom Aetna Medicare Advantage PPO plan.
What are the time frames or deadlines for a response to a prior authorization request?
Prior authorization timing for a non-urgent scheduled service may take up to three days. If it’s urgent it may take one day and, in many cases, it may occur on the same day. For emergency services, prior authorization is not required.