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Embrace Your Advantage: Understanding Prior Authorization for Medicare Advantage



The Joint Health Management Board’s (JHMB) goal is to keep you, as a retiree of the Fresno Unified School District on the Aetna® Medicare Advantage PPO plan, informed and up to date on the benefits and changes to your health coverage, as well as how to use them.

One key term to know is “prior authorization.”

What is Prior Authorization?

We may need more details before we can approve some care options and products. We call this “prior authorization.” Sometimes, we may call it “precertification” or “preapproval.” These all mean the same thing. It’s the process of confirming if your plan will cover a certain service or prescription drug.

Why It’s Needed

Some services or medicines cost more than others, and some have higher risks. Prior authorization lets Aetna® check to see if a treatment or medicine is necessary.

This helps:

  • Keep you safe
  • Keep your costs down

When You Need It

When you see an in-network doctor, they’ll help you get the prior authorization you need. Check with your doctor to make sure you have it before you get care.

Here is a list of some of the services and medicines that need prior authorization:

  • Transplants
  • Certain types of genetic testing
  • Hip and knee replacements
  • Radiology or imaging services
  • Cardiac catheterizations and rhythm implants
  • Pain management
  • Sleep studies
  • Radiation therapy
  • Peripheral arterial disease
  • Out-of-network care
  • Fertility services

How Prior Authorization Works

  1. If your doctor thinks you need a service or medicine that requires prior authorization, they’ll let Aetna® know. They do this by sending Aetna® a request. You do not have to do anything. Your doctor will manage this process.
  2. Once Aetna® has all the details they need, Aetna® will review the request. If they do not receive all the details needed, this may delay when they can begin the review.
  3. Aetna® will let you and your doctor know what they decide via letter. The review process can take up to two weeks.
  4. If you don’t agree with Aetna®’s decision, you can appeal it. The letter sent regarding the precertification decision will have the details on how to file an appeal request, along with the address to submit. You may also call the number on your member ID card and request an expedited appeal.

You have 60 days from the date of the letter to request an appeal.

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. Plan features and availability may vary by service area. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.

Medicare Members: If the request is for prescription drugs or services not yet received, Aetna® must notify the member (and the prescribing physician or other prescriber involved, as appropriate) of our decision no later than 24 hours after receiving the physician's or other prescriber's supporting statement for expedited cases. Or no later than 72 hours after receiving the physician's or other prescriber's supporting statement for standard cases.

If the exception request involves reimbursement for prescription drugs or services already received, Aetna® must notify the member (and the prescribing physician or other prescriber involved, as appropriate) of the decision (and make payment when appropriate) no later than 14 calendar days after receiving the request.

What To Do if You Have Further Questions on Prior Authorization

Call the Aetna® Customer Service Team

Connect with Aetna® regarding questions about prior authorization, denials, and appeals.

1-888-267-2637 (TTY: 711)
Monday through Friday
8 a.m. to 9 p.m. ET

Receive Assistance From the Fresno Unified Benefits Department

(559) 457-3520
Monday through Friday
8 a.m. to 5 p.m. PT

You can also call the Benefits Office if you have other benefits-related questions or concerns.

Contact the Joint Health Management Board

We want to hear from you about your healthcare plan experiences, and we are committed to providing you with the resources to manage your wellness effectively. Email us at, or ask us a question.

Learn more about plan options for retirees.
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