Insurance and Prior Authorization

1. Verifies coverage. At the first contact, the intake team collects the patient's insurance details, confirms the plan's coverage of the prescribed medication and explains what the plan covers and any out-of-pocket cost.
2. Obtains prior authorization. Where the plan requires it, the team submits the request with the documents the prescriber's office provides, follows up with the plan, and works with the office on any further information the plan asks for. The patient and the office are told when the decision arrives.
3. Bills the plan. The team prepares and submits the claims, provides invoices and follows up with the plan on payment.
4. Helps with the balance. Patient support answers billing questions, can arrange a payment plan, and helps the patient apply for copay assistance, foundation grants and manufacturer programs when a copay stands in the way.

Delivery is scheduled once the plan has approved the medication. Next-day delivery is available; timing varies by location.

The health plan sets the timeline, and it varies by plan, by medication and by how complete the request is. MedRx does not publish a turnaround time. What shortens the wait is a complete referral: the prescription, the diagnosis, the latest visit note, recent lab results and the insurance details, listed on How to refer a patient. The intake team submits the request as soon as it has them and follows up with the plan.

For Medicare Advantage plans, state Medicaid and CHIP programs and Medicaid managed care plans, a CMS rule in force from January 1, 2026 requires a prior authorization decision within 72 hours for an expedited request and seven calendar days for a standard one. That rule covers medical items and services and does not apply to prior authorization decisions for drugs, so for a medication the plan's own rules still apply.

MedRx works with Aetna, Blue Cross Blue Shield, Cigna, Humana, Medicare, UnitedHealthcare and many other plans. Each state runs its own Medicaid program and enrols a pharmacy separately, so Medicaid coverage varies by state; the page for each state on Where We Serve says whether MedRx bills its program. The intake team confirms coverage with the patient's plan before therapy starts.

Which part of Medicare applies depends on the medication and on how it is given. From medicare.gov and CMS:

• Part B covers home infusion equipment and supplies as durable medical equipment, including pumps, IV poles, tubing and catheters, and the home infusion therapy services needed to give certain intravenous or subcutaneous drugs at home, such as nursing visits, caregiver training and patient monitoring. In most cases the patient pays 20% of the Medicare-approved amount, and the Part B deductible applies to the equipment and supplies. The home infusion therapy services benefit began in January 2021, for drugs given through a pump that is an item of durable medical equipment.
• Part B also covers certain drugs infused through covered equipment such as an infusion pump, most injectable and infused drugs a licensed provider administers, and immune globulin given at home for a primary immune deficiency diagnosis when the provider finds it medically appropriate.
• Part D covers many drugs that Part B does not. The plan's formulary says which medications it covers.

MedRx's intake team checks which part applies to the prescribed medication and what the patient's plan requires before the first delivery. For immune globulin, the IVIG and SCIG home infusion page answers "Does Medicare cover home infusion therapy?" in its reviewed questions.

When the plan approves the medication but the copay is more than the patient can manage, MedRx helps the patient find and apply for copay assistance, foundation grants and the manufacturer's patient support program. Each medication page names the manufacturer's program where one exists. Eligibility is decided by each program, not by MedRx.

Prior authorization starts with the referral. The office sends the prescription or the specialty referral form, the latest visit note, recent lab results, the patient's insurance details and the patient's demographics with height and weight, by fax or through Quick Referral. How to refer a patient has the full checklist and what intake does with it.