Prior authorization changes coming for diabetic insulin supplies for Medicare members

Effective Jan. 1, 2025, diabetic supplies will require an insulin claim, or prior authorization confirming insulin use, to be covered under the Medicare Part D benefit. This change only impacts Priority Health Medicare members.

Why the change?

Per Medicare law, diabetic supplies can only be covered under the Medicare Part D benefit when they’re used for the injection of insulin. To ensure we’re complying with federal regulation, prior authorization requirements are being added to diabetic insulin supplies. This authorization will impact members who haven’t filled a prescription for insulin within six months of obtaining diabetic insulin supplies.

What do you need to do?

If your Medicare patient gets diabetic insulin supplies and they have a claim for insulin on file with us, no action is needed. If they're obtaining diabetic insulin supplies without an insulin claim, or without having filled a prescription for insulin within 180 days of obtaining insulin supplies, you’ll either need to submit prior authorization confirming insulin use or have your patient fill an insulin prescription through their Medicare Part D pharmacy benefit.

How to submit prior authorization

You can submit a prior authorization request by fax at 877.974.4411 or phone at 800.466.6642. Don’t have a prior authorization request form? You can find them on the Medicare Approved Drug List page in our Provider Manual, under Downloads.

How are we communicating this to members?

Impacted members were mailed letters informing them of what steps they can take prior to Jan. 1, 2025.

Questions?

Contact our Pharmacy provider helpline at 800.466.6642.