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Message
re: The Prior Authorization Process for Medicine
Posted on 3/7/24 at 10:34 am to Jcorye1
Posted on 3/7/24 at 10:34 am to Jcorye1
quote:
I'm not going to apologize for telling the truth on forms provided by the company that created and sells the drug to receive a better price, with help from my former and current doctors.
nor am i saying you should... i'm simply pointing out that that cost doesn't simply "disappear".... it's shifted to someone else...
drug costs are high b/c it takes A LOT of time, money, and effort, to develop them, but realistically, a lot of drugs are developed now with the explicit purpose of being a cash grab... there is likely already something that has BEEN developed, and is available as a generic b/c its older and off patent, that will work for whatever condition it is you are treating...
ain't like they are making "cures" for things, b/c the money ain't in a "cure"... it's all about making money off of something that is known to work, but is slightly different than the last drug, for whatever condition, that just came out and made tons of money for the developing company...
Posted on 3/7/24 at 10:38 am to LSUFanHouston
Literally just went through this process. Was on the the third and final bottle of a 3 bottle prescription. Arrive at the pharmacy to pick it up to find that I am being charged 4 times the price I was charged for the previous two bottles. I tell the pharmacist and she says, "So do you want it?" I say yes because I am down to two days supply and have to have it. The pharmacist note on the bag says "insurance will not cover" with no further explanation.
I get home and call the insurance which leads me to an hour long phone call with a foreign representative who seems to have no idea what's going on. She eventually concludes that the insurance only covers 84 pills in a 6 month period and my prescription is for 90. Ok, so why didn't the insurance cover pills 61-84 in my last bottle? She says she is sending me a form to apply for reimbursement to my email address. Form never arrives.
I then appeal to an intermediary that our company uses when we have insurance problems. She comes back and tells me the medication needs "pre-authorization" and that my doctor needs to send more information to the insurance company for them to grant this. Now I call the doctor's office who says they received nothing from either the insurance company or the pharmacist requesting any information for "pre-authorization." The doctor calls the pharmacy and the pharmacist tells them they will not send anything over since I already picked up the medication. At this point I'm getting pretty goddamn irritated and go back to the intermediary. She contacts the insurance company, who says they will send the request direct to the doctor. A few days later I get a voicemail that the "pre-authorization" has been denied with no explanation as to why. Now I get to call the insurance company again. I get another foreign representative and they tell me that I am denied but cannot provide a reason and, once again, that they only cover 84 of the 90 pills. I tell them great, then why cannot I not get reimbursed for the 24 pills that would make a total of 84. I can, she says, and she will email me the reimbursement form. I tell her that's what I was told before and I never received it. Then I was told I needed pre-authorization before I could be reimbursed. She confirms my email info is correct and says they are emailing it over...it never arrives.
I end up having to mail a reimbursement request and I am still awaiting the outcome. The kicker is I just received something in the mail explaining that the pre-authorization was denied because the doctor's office did not provide the requested information. At this point I don't give a frick about paying full price for 6 of the pills in the final bottle, which apparently is all the "pre-authorization" is attempting to get covered. The whole process has been totally fricked and I have no idea where the breakdown even occurred to kickstart this whole clusterfrick. It seems apparent to me that both the pharmacy and the insurance have failed to function properly in this chain and I, the consumer, have been left to waddle through multiple different entities to attempt to sort it out after the fact.
I get home and call the insurance which leads me to an hour long phone call with a foreign representative who seems to have no idea what's going on. She eventually concludes that the insurance only covers 84 pills in a 6 month period and my prescription is for 90. Ok, so why didn't the insurance cover pills 61-84 in my last bottle? She says she is sending me a form to apply for reimbursement to my email address. Form never arrives.
I then appeal to an intermediary that our company uses when we have insurance problems. She comes back and tells me the medication needs "pre-authorization" and that my doctor needs to send more information to the insurance company for them to grant this. Now I call the doctor's office who says they received nothing from either the insurance company or the pharmacist requesting any information for "pre-authorization." The doctor calls the pharmacy and the pharmacist tells them they will not send anything over since I already picked up the medication. At this point I'm getting pretty goddamn irritated and go back to the intermediary. She contacts the insurance company, who says they will send the request direct to the doctor. A few days later I get a voicemail that the "pre-authorization" has been denied with no explanation as to why. Now I get to call the insurance company again. I get another foreign representative and they tell me that I am denied but cannot provide a reason and, once again, that they only cover 84 of the 90 pills. I tell them great, then why cannot I not get reimbursed for the 24 pills that would make a total of 84. I can, she says, and she will email me the reimbursement form. I tell her that's what I was told before and I never received it. Then I was told I needed pre-authorization before I could be reimbursed. She confirms my email info is correct and says they are emailing it over...it never arrives.
I end up having to mail a reimbursement request and I am still awaiting the outcome. The kicker is I just received something in the mail explaining that the pre-authorization was denied because the doctor's office did not provide the requested information. At this point I don't give a frick about paying full price for 6 of the pills in the final bottle, which apparently is all the "pre-authorization" is attempting to get covered. The whole process has been totally fricked and I have no idea where the breakdown even occurred to kickstart this whole clusterfrick. It seems apparent to me that both the pharmacy and the insurance have failed to function properly in this chain and I, the consumer, have been left to waddle through multiple different entities to attempt to sort it out after the fact.
Posted on 3/7/24 at 11:29 am to ChewyDante
quote:
I tell the pharmacist and she says, "So do you want it?" I say yes because I am down to two days supply and have to have it. The pharmacist note on the bag says "insurance will not cover" with no further explanation.
without reading any further, i'm guessing you deal with a chain retail pharmacy, correct?
Posted on 3/7/24 at 11:31 am to LSUFanHouston
You're making the argument for single payer.
Posted on 3/7/24 at 11:37 am to Jim Rockford
quote:
You're making the argument for single payer.
exactly, but without realizing it, and likely would adamantly oppose singlepayer, with labels like "socialism" surely somewhere in the rebuttal
at this point, there is NO middle ground... it's either keep doing what we are currently doing, or go to single payer.... too many people have entered the fray and learned how to make a shite ton of money off healthcare to think we'll regress to the mean any time soon.... it will only get worse, never better, if we continue on the same path
Posted on 3/7/24 at 11:58 am to chRxis
quote:
without reading any further, i'm guessing you deal with a chain retail pharmacy, correct?
That is correct. Spoke to an associate of mine about what was going on who says he actually stopped using this particular pharmacy location on account of their consistent laissez-faire attitude on giving a frick. This is my first time filling a prescription at this location so I'm thinking I will cut my losses and change to a new one. The doctor's office implied that they should have received the pre-authorization request from the pharmacy before I ever got the call that the prescription was ready. So I'm thinking the problem was initiated with their oversight.
Posted on 3/7/24 at 12:03 pm to ChewyDante
quote:
That is correct
do yourself a favor and go to an independent pharmacy... where you located?
Posted on 3/7/24 at 12:05 pm to ChewyDante
quote:
The doctor's office implied that they should have received the pre-authorization request from the pharmacy before I ever got the call that the prescription was ready.
this is correct
quote:
the problem was initiated with their oversight.
it wasn't oversight... it was lack of care for their patient (you) and their needs...
basically, that's a shitty pharmacist, and subsequently, a shitty pharmacy
Posted on 3/7/24 at 12:23 pm to chRxis
quote:
do yourself a favor and go to an independent pharmacy... where you located?
Slidell
Posted on 3/7/24 at 1:15 pm to teke184
quote:
n my experience, PAs end up being a big fight back and forth between the doctor, insurance, and pharmacy which tends to get bogged down if you aren’t going to pull a bunch of time out of your day to yell at everyone involved.
That's the thing. There are so many people involved, I don't even know who to yell at. I assume they will just all point fingers at each other.
Posted on 3/7/24 at 1:23 pm to Jim Rockford
quote:
You're making the argument for single payer.
I would not mind single payer if the signle payer was not the government, and it was a non-profit set up with health outcomes as the number 1 objective.
I'd be fine with the pharmacy, insurer, and doctor all in the same system... except that such a system probably would be a for-profit corporationa and now they would be trying to screw you three times instead of one.
Posted on 3/7/24 at 1:31 pm to ChewyDante
quote:
Slidell
ahh... yeah, i don't have any independent pharmacy knowledge out that way.... we have a few sister stores out in Hammond and Ponchatoula, but not out that way....
but go to an independent pharmacy, if you can....
Posted on 3/7/24 at 1:33 pm to LSUFanHouston
quote:
I would not mind single payer if the signle payer was not the government, and it was a non-profit
it doesn't work this way... it's one or the other, chief... again, there is NO middle ground, at this point.... you can't put the toothpaste back in the tube
Posted on 3/7/24 at 1:47 pm to chRxis
quote:
ahh... yeah, i don't have any independent pharmacy knowledge out that way.... we have a few sister stores out in Hammond and Ponchatoula, but not out that way....
but go to an independent pharmacy, if you can....
Interestingly enough, I got to a Walmart pharmacy. The pharmacy is amazingly well run, at least it has been to date with all of my experiences.
Everything else about this Walmart is turrible, awful, etc, but whoever is in charge of the pharmacy is doing a great job.
Posted on 3/7/24 at 1:50 pm to iwantacooler
I am impressed when I see a PA approved the same business day, I should add I’m rarely impressed.
Posted on 3/7/24 at 2:32 pm to Thedillyplate
I just had an orthopedic surgeon from UMMC get one approved today in 2 hours from the time I sent it to him. It’s all about the provider and their staff. Of course the pharmacy has to do their part in sending it over in a timely manner. It’s been previously mentioned, but independent pharmacies are the best at this and pretty much every other thing retail pharmacies do.
I’m not saying the majority get them done within the day, but to say it will be a week at best just isn’t factual.
I’m not saying the majority get them done within the day, but to say it will be a week at best just isn’t factual.
This post was edited on 3/7/24 at 2:35 pm
Posted on 3/7/24 at 4:53 pm to PurpleandGold Motown
quote:
PAs take 24-48 hours and are valid for a year. So it's really a minor inconvenience most of the time
This is far from the norm.
It’s more likely that the doctor’s office will get the run around about different info or proof of testing that’s needed. Some insurance companies will even do the same ‘you need to speak to a different department’ carousel that cable companies use when you try to discontinue service.
All they want you to do is get frustrated and give up.
Posted on 3/7/24 at 5:21 pm to StringedInstruments
quote:
Y’all are scaring me. I use ACCREDO for Dupixent. It’s been fine so far, but I definitely didn’t like the insane process it took to get my first dosage.
Be careful if you use the automated texting system. There are some real horror stories out there about people responding "Yes" when accredo texts them its time to refill. Accredo then sends the meds, followed by a bill costing thousands of dollars. All b/c A. you didn't know your insurance only covered 6 months of it. or B. They fricked something up and now you have to fight it out with them.
Posted on 3/7/24 at 7:19 pm to StringedInstruments
quote:
I do have SaveOnSP though. Not sure if that will affect any unexpected bills.
It’s not the billing that was an issue for me, it was the prior authorizations that they just decide they need out of nowhere. One minute you’ve got a prior authorization that’s good for a year. But then three months go by and they don’t fill your meds. So you call them and they tell you they need a prior authorization and that your first one is expired. They tell you they’ll fax it over to your doctor. Two weeks go by and you call your doctor- they say accredo hasn’t sent anything over, but the prior authorization they gave is good for a year. It’s back and forth with those fools and I’m convinced that their job is to make you give up.
Posted on 3/13/24 at 1:50 pm to ChewyDante
Update.
I called the insurance company last Friday to see what was up, I was told that they did not receive the PA forms.
So I called my doctor, again, and they said they would send, again.
I called the insurance company today, again, they said they didn't have anything to process. And I just went ballistic on them.
The end result of the call was they did a "temporary" one-fill authorization of both medicines, and they will directly reach out to my doctor to figure out why they seem to be unable to get the information.
I called the insurance company last Friday to see what was up, I was told that they did not receive the PA forms.
So I called my doctor, again, and they said they would send, again.
I called the insurance company today, again, they said they didn't have anything to process. And I just went ballistic on them.
The end result of the call was they did a "temporary" one-fill authorization of both medicines, and they will directly reach out to my doctor to figure out why they seem to be unable to get the information.
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