Health insurance policies and coverage vary greatly. That is why it is important to understand how your specific plan works and how that can affect your retina care.

Some health plans require a referral from your primary care physician to receive care from any specialist, including our physicians here at Texas Retina Associates. Some plans also require that you choose a physician in their network. In addition, many insurance plans, especially Medicare Advantage plans, are increasingly requiring a prior authorization for certain procedures and prescriptions. This means that the health plan has to provide you and us with approval before care is provided in order for the plan to cover the cost. 

Unfortunately, the need for prior authorization can sometimes create a delay in receiving care. Some Medicare Advantage plans even require prior authorization for each visit at our office as well as for each intravitreal injection, a common treatment for retina conditions like age-related macular degeneration. 

Please know that our team does all we can to assist you and expedite these prior authorizations to help you receive the care you need when you need it. While our office is ultimately responsible for submitting the prior authorization request, here are a few steps you can take to stay informed and assist with the process:

  1. Review your health plan’s policy documents to determine if any treatments or medications require a prior authorization.
  2. If prior authorization is required, learn the process that your plan requires. You should be able to find this on the plan’s website, or you can call the member services phone number found on the back of your health insurance card.
  3. Double check that you meet all of the requirements and ensure that we have all of the necessary information before we submit the prior authorization.
  4. If your request is approved, be sure to abide by any rules the insurance company provides for obtaining care. If your request is denied, be prepared to appeal the decision and know how that process works. 
  5. Keep detailed records of all prior authorizations and make note of when they expire. This allows you to be proactive in securing a new prior authorization. It is best to do so at least a month before the current one expires to help minimize any lapses in care or treatment. 

We understand that insurance coverage can be confusing and that the prior authorization process can be a burden. The American Academy of Ophthalmology has been pushing for change, and there is currently a bipartisan group of legislators in the United States Congress trying to put forth legislation that would improve and simplify this process for seniors. In the meantime, our team will do everything we can to minimize the delays and frustrations that prior authorizations can have on your care. 

Prior to your appointment with Texas Retina Associates, please check with your insurance provider, or contact us at 800-872-2020, option 4, or here to verify your specific coverage and benefits.