re: The Prior Authorization Process for Medicine

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.

You're making the argument for single payer.

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without reading any further, i'm guessing you deal with a chain retail pharmacy, correct?

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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.

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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.

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this is correct

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the problem was initiated with their oversight.

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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

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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.

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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.

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You're making the argument for single payer.

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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.

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I would not mind single payer if the signle payer was not the government, and it was a non-profit

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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

I am impressed when I see a PA approved the same business day, I should add I’m rarely impressed.

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PAs take 24-48 hours and are valid for a year. So it's really a minor inconvenience most of the time

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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.

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I do have SaveOnSP though. Not sure if that will affect any unexpected bills.

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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.