Prior approval
Prior approval is a payment check.
Prior approval means the health plan reviews a medicine payment request in advance; the plan may call this prior authorization.
Follow the plan’s payment decision
Keep the decisions distinct
A formulary is the list of medicines included by a health plan. As checked September 26, 2026, a medicine can qualify for Medicare payment while your own plan still needs to decide about paying. Your plan still checks its list of covered medicines and any requirement for approval before payment.
- Ask whether the exact medicine and form are on the list.
- Ask what the plan needs from the clinician.
- Ask how to check the outcome and your expected share of the bill.
Make the waiting period clear
Before paying a care fee, ask how the service handles a request that has no plan decision yet.
- Who sends the information?
- How will I hear the decision?
- What fees still apply if payment is refused?
Ask what the answer leaves open
A refusal can leave you with questions about both care and cost. Keep those questions together for the next conversation.
- Ask the plan why it refused payment.
- Ask the clinician to discuss the care options again.
- If considering cash payment, ask for its full terms before choosing it.