re: The Prior Authorization Process for Medicine

Prior authorization is just another tool to save insurance companies money and that's it.
It's an onerous and inefficient process that's bad for doctors, patients, pharmacists but good for insurance companies.

Additionally, it's unpaid work for doctors and their staff. There's a reason many offices are starting to make patients come in to watch them fill out or perform prior auths, or charging extra fees for the paper work involved in prior auths. In medicine, it's not the norm to be able to bill patients for work performed outside of the office visit.

Pharmaceutical companies don’t give a damn about anyone, they just want you to live a little longer so they can make a little more money off of you. You don’t have to go back far to see a famous NFL player advertising a shot for what’s now nothing more than a cold for most people in 2024. Tobacco companies can’t advertise on TV anymore but the companies that magically appeared with a so-called vaccine, can continue to promote a lie.

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My doctor is great but they are part of The Big O now and the staff isn’t the best at this stuff

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A good nurse can help expedite the appeals process for doctors and patients. It’s work but a nurse who has experience navigating the system (insurance companies) is a valuable asset to a physician and his office. The problem is these nurses get overworked and turnover becomes an issue, especially if they aren’t paid shite.

The problem for you is the Big O is notorious for overworking and underpaying their staff which leads to high turnover

I think there was some legislation passed recently that sets a limit on the time insurance has to process a PA. I’ve been going through the same process as OP and have not been able to get medicine I take every two months via infusion because of this ridiculousness. It’s incredible that the allow this to happen.

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You can blame the pharmaceutical companies for a lot of shite but prior authorizations ain’t one of them.

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Prior authorization was the point for the OP, but I went left with my post. But, everything I said is true.

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eah it's entirely a plan thing. One PBM I had required a PA for Adderall, but also required that I get brand... it made no sense. The labor costs to do that PA were more expensive than paying out at 100% for the very very short duration I even had that plan

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It, sadly, makes perfect sense for a few reasons:
1) the drug companies don’t pay what you would pay for branded drugs. They’re allowed to make deals to get branded drugs cheap to not allow the generics on formulary (or in other words, two competing drug companies exist, one pays a huge amount to the PBM to be the exclusive med on the formulary and the competitor not being covered. The company now has the money with which to buy the drug for cheap). I have a friend who used to work in the lab that made a specific drug. An Indian company infringed on their patent. There was a settlement. One of the final terms of the settlement was for the Indian company to be allowed to sell the drug, but it required them to do so at a much HIGHER price than originally intended (roughly the price of the branded medication that they conveniently quit producing because they were getting paid by the generic maker who was now making huge margins)


2) the process isn’t about anything but finding new reasons to deny coverage. They don’t care what you need or what’s indicated. They care about 1 in every 20-30 getting set aside and a different, more favorable (to them) medication being prescribed.


Here’s an old article that gives decent overview into a handful of the practices. Here is a short, funny video with an overview of some of the practices.

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Don't you just love when the DR prescribes you the needed meds and the insurance won't agree. Or how about when they RX you to take 1 per day of a tablet and the insurance only allows you to receive 20 per month and not allow you to purchase any extras for the days not covered without insurance? What am I supposed to do the other 10 days per month?

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That’s the American healthcare system. I’m not saying we need to go the Canadian healthcare system but if we can send billions around the world every year, it seems like we could take care of our own. I’m simply saying our taxpayer money should be spent on Americans First before said money leaves this country.

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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.

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Of course this would be better. You can thank Obama, the Dems, and everyone who voted for them.

Insurances companies suck. All of them.

In addition to the constant authorizations or other hoops, I love it when they swap an RX with a generic and claim there is no difference.

Except when there is clearly a difference, and you have to get other paperwork and your doctor to approve the brand name.

Do people that work for insurance companies have to use their own insurance plans?