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Message
The Prior Authorization Process for Medicine
Posted on 3/6/24 at 6:29 pm
Posted on 3/6/24 at 6:29 pm
Last year I was put on a medication that requires a prior authorization. It was a major pain but it finally got appoved.
At the end of the year, we changed health insurance companies. I had a feeling this wasn't going to be smooth, so just before year end, I got a three month supply of that medicine, plus a second one I take.
Last week I go to the pharmacy to refill. I give them my new insurance info. I'm told not only do I need to get a new prior authorization, but that this insurance company requires a prior authorization on my other medication as well. So now I need two.
Pharmacy says they will fax a form to my doctor, for him to fill out, and send to insurance company. Then the insurance company will let the pharmacy know if approved or not.
It occurs to me that I am at the mercy of three different groups... my doctor, the pharmacy, and the insurance company. I have absolutely no control ove the process... basically I just have to wait for multiple people to do their jobs.
I guess the alternative is I can just not deal with insurance and pay the cash price for these two drugs. Even with discount cards it's over $1,000 per month for the two of them.
It's times like this when I really wonder if we would not be better off going back to using insurnance only for major issues (at a much reduced premium cost) and we just handle our own for drugs and doctor visits etc.
At the end of the year, we changed health insurance companies. I had a feeling this wasn't going to be smooth, so just before year end, I got a three month supply of that medicine, plus a second one I take.
Last week I go to the pharmacy to refill. I give them my new insurance info. I'm told not only do I need to get a new prior authorization, but that this insurance company requires a prior authorization on my other medication as well. So now I need two.
Pharmacy says they will fax a form to my doctor, for him to fill out, and send to insurance company. Then the insurance company will let the pharmacy know if approved or not.
It occurs to me that I am at the mercy of three different groups... my doctor, the pharmacy, and the insurance company. I have absolutely no control ove the process... basically I just have to wait for multiple people to do their jobs.
I guess the alternative is I can just not deal with insurance and pay the cash price for these two drugs. Even with discount cards it's over $1,000 per month for the two of them.
It's times like this when I really wonder if we would not be better off going back to using insurnance only for major issues (at a much reduced premium cost) and we just handle our own for drugs and doctor visits etc.
26
Posted on 3/6/24 at 6:31 pm to LSUFanHouston
quote:
basically I just have to wait for multiple people to do their jobs.
Welcome to Earth?
Posted on 3/6/24 at 6:34 pm to rundmcrun
quote:
Welcome to Earth?
Correct
I'm a control freak lol
Posted on 3/6/24 at 6:36 pm to LSUFanHouston
quote:
It occurs to me that I am at the mercy of three different groups... my doctor, the pharmacy, and the insurance company. I have absolutely no control ove the process... basically I just have to wait for multiple people to do their jobs.
You’re really at the mercy of the insurance company. They make it as hard as possible to get a prior authorization.
They make it difficult on doctors and pharmacists too and try to make everyone quit trying to get it.
Posted on 3/6/24 at 6:37 pm to LSUFanHouston
Hopefully it’s not accredo pharmacy. Express Scripts made me use them for dupixent shots and it was a nightmare.
Posted on 3/6/24 at 6:50 pm to LSUFanHouston
quote:
occurs to me that I am at the mercy of three different groups... my doctor, the pharmacy, and the insurance company. I have absolutely no control ove the process... basically I just have to wait for multiple people to do their jobs.
This is pretty much it.
And pharmacy is the middle man who gets the honor of often delivering the bad news that it isn’t approved . Once we send the fax, it’s out of our hands completely.
But even if it isn’t approved, you can still appeal the decision. That’s encouraged . That requires the Dr to fax more info to the insurance directly .
Good luck . And hope you didn’t need the meds right away bc PA’s take minimum a week to complete and that’s if everyone is doing what they’re supposed to do
EDit: some insurances will reach out and say hey Drug A for John smith was approved or denied. So we know to rerun the claim. But a lot of plans don’t, so after a week or so, recall the pharmacy to get them to rerun the claim for whatever drug it is
It’s shittey. I agree. I see it all day every day.
This post was edited on 3/6/24 at 6:52 pm
Posted on 3/6/24 at 6:56 pm to LSUFanHouston
quote:
It occurs to me that I am at the mercy of three different groups... my doctor, the pharmacy, and the insurance company.
No.
You are at the mercy of your insurance company.
A physician can write any prescription that is appropriate.
A pharmacist can fill any prescription that is written - unless it is Ivermectin and then they act like providers giving their opinion.
Your insurance is the problem. They can deny anything and change their opinion from month to month.
Posted on 3/6/24 at 7:04 pm to LSUFanHouston
Healthcare sucks in this country now. Thank a democrat
Posted on 3/6/24 at 7:07 pm to kywildcatfanone
quote:
Thank a democrat
RINO’s like “Liz”ard Cheney, and John McCain.
Posted on 3/6/24 at 7:26 pm to adavis
quote:
Hopefully it’s not accredo pharmacy. Express Scripts made me use them for dupixent shots and it was a nightmare.
Holy christmas don't get me started on those bastards. Had the exact same situation/medication, took forever to finally start getting meds. Then they hit me with a surprise $4000 bill one month. They are absolute scum. I've decided to just not take dupixent anymore b/c I can't deal with that headache.
Posted on 3/6/24 at 7:34 pm to indytiger
Look into Pharmacy Benefit Managers and their role with Insurance Companies and Big Pharma and get ready to puke.
Posted on 3/6/24 at 7:39 pm to LSUFanHouston
quote:
It occurs to me that I am at the mercy of three different groups..
Not trying to pile on, but as someone who works in Healthcare there's a very good chance it will go through the hands of someone who is really shitty at their job too.
Posted on 3/6/24 at 8:05 pm to indytiger
quote:
Holy christmas don't get me started on those bastards. Had the exact same situation/medication, took forever to finally start getting meds. Then they hit me with a surprise $4000 bill one month. They are absolute scum. I've decided to just not take dupixent anymore b/c I can't deal with that headache.
That’s what I ended up doing too. My issues came right back after I started taking it too. Accredo and Express Scripts should be forced out of business for the shady stuff they pull.
Posted on 3/6/24 at 8:06 pm to rintintin
There are no longer hard copy scripts, every thing on line, that the patient cannot see.
If I get into a jam with Aetna over a prescription , Progresso Mexico is just 2 hours away. cash price attractive, no script required
If I get into a jam with Aetna over a prescription , Progresso Mexico is just 2 hours away. cash price attractive, no script required
Posted on 3/6/24 at 8:07 pm to Lawyered
quote:
And hope you didn’t need the meds right away bc PA’s take minimum a week to complete and that’s if everyone is doing what they’re supposed to do
This is just not true. While I hate the PA process as much as the next guy, I often see prescribers around here (central MS) have their part done and the insurance approve them within the same business day. On the other hand I see some prescribers just flat out refuse to spend any time on it. A lot of it depends on the prescribers office staff and the emphasis they put on the process.
Posted on 3/6/24 at 8:17 pm to LSUFanHouston
Authorizations are yet another modality used by insurance companies to prolong needed care (read: less spending for them within a given period of time) and it creates more hurdles for clinicians and patients to overcome.
Many HMO plans require authorizations through the PCP for a mere office visit with a specialist....even if you've already been established with that doctor. Meaning, in order to keep seeing your specialist who has been treating you for months or years, the clinic staff at your specialist's office has to submit a formal "authorization request" to your PCP for your next visit. Your PCP's clinical staff then has to submit the claim to the insurance company, and then work with the insurance company to obtain an auth/claim number, and then they have to submit that information back to the specialist's office...all just for one single 10 minute office visit. It's just an absolutely absurd system.
Authorizations, co-pays, co-insurance, etc. Every few years health insurance companies layer on additional checks and balances into the system that creates headaches for everyone involved...except for themselves.
Many HMO plans require authorizations through the PCP for a mere office visit with a specialist....even if you've already been established with that doctor. Meaning, in order to keep seeing your specialist who has been treating you for months or years, the clinic staff at your specialist's office has to submit a formal "authorization request" to your PCP for your next visit. Your PCP's clinical staff then has to submit the claim to the insurance company, and then work with the insurance company to obtain an auth/claim number, and then they have to submit that information back to the specialist's office...all just for one single 10 minute office visit. It's just an absolutely absurd system.
Authorizations, co-pays, co-insurance, etc. Every few years health insurance companies layer on additional checks and balances into the system that creates headaches for everyone involved...except for themselves.
Posted on 3/6/24 at 8:31 pm to kywildcatfanone
quote:
Healthcare sucks in this country now. Thank a democrat
And every republican that went along with the whole “you can read the bill after it passes” bs Pelosi shoved down their throats
Posted on 3/6/24 at 8:50 pm to LSUFanHouston
People complained about the cost of medical care, so the government got involved. Of course, that meant the lobbyists for the insurance and pharmaceutical companies got involved too.
So, instead of you and your doctor making decisions about your health care, it's the government, the insurance company, and the pharmaceuticals telling you and your doctor how things will be.
And all this is going to save you, on average $2500 a year.
It was a great deal, wasn't it?
So, instead of you and your doctor making decisions about your health care, it's the government, the insurance company, and the pharmaceuticals telling you and your doctor how things will be.
And all this is going to save you, on average $2500 a year.
It was a great deal, wasn't it?
Posted on 3/6/24 at 8:56 pm to Trevaylin
quote:I just got a hard copy script from my PCP yesterday because I wasn’t sure which pharmacy I was going to use.
There are no longer hard copy scripts, every thing on line, that the patient cannot see
Posted on 3/6/24 at 9:05 pm to Lawyered
quote:
And hope you didn’t need the meds right away bc PA’s take minimum a week to complete and that’s if everyone is doing what they’re supposed to do
Yeah pharmacy said 1-2 weeks. I’m good through most of March because I filled 3 months around Christmas
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