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SAS Name
PRIOR_AUTHORIZATION_YN
This is a CCW-derived field that indicates whether the prescription was subject to prior authorization, according to the benefit structure and formulary for the beneficiary’s plan.
Starting in 2010, this variable included in the Formulary file (rather than the PDE file).
Source: PDE and Plan Characteristics (derived)
| Code | Code value |
|---|---|
| 1 | Prior authorization required |
| 0 | Prior authorization not required |
| Null |
Part D plan sponsors submit the pricing, tiers, and formularies for their plan benefit packages to CMS via the Health Plan Management System (HPMS).
This includes information on which drugs are subject to prior authorization, which means that a physician must get the plan’s approval in advance before prescribing the drug. The CCW creates this variable based on the beneficiary’s plan of record, which is identified using the Part D contract and plan benefit package of record (the PLAN_CNTRCT_REC_ID and PLAN_PBP_REC_NUM variables). For a small number of beneficiaries, particularly those who changed plans around the time of the fill, the variable may not be an accurate reflection of whether the PDE was subject to prior authorization.