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Message
re: The Prior Authorization Process for Medicine
Posted on 3/7/24 at 9:17 am to PurpleandGold Motown
Posted on 3/7/24 at 9:17 am 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.
Great point. I think I’ll get a stamp made for all the ones that have to be done every year that says, “Patient stable on medication for ___ years. My cell number is (included), please call me if you decide to deny coverage for whatever arbitrary reason on a stable patient on an appropriate regimen.”
0
Posted on 3/7/24 at 9:18 am to concrete_tiger
quote:
Do people that work for insurance companies have to use their own insurance plans?
I have a relative who does.
She constantly complains about their plan lol
Posted on 3/7/24 at 9:19 am to Hopeful Doc
quote:
But I would dare them to deny millions of paying customers with feet to walk away and see how long the charade lasts.
Meh. Most people get their insurance through work so that’s not really an option.
And most companies these days use a broker, and who knows how much corruption / kickbacks are involved there
Posted on 3/7/24 at 9:23 am to LSUFanHouston
Just the BS about "faxing" is ridiculous...
I wore their arse out when my sweethearts needed meds, though
Sometimes you have to be a bit hard-nosed to get things done.
Posted on 3/7/24 at 9:23 am to LSUFanHouston
I’ve been on a prior auth med for 20 something years. Yet, each year we have to play the game with the ins company.
Posted on 3/7/24 at 9:25 am to LSUFanHouston
quote:
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.
It’s times like this I get pissed off that we had a system that worked MUCH better than got fricked over with the intention of transitioning us to socialized medicine.
The system wasn’t perfect but it was a lot better than this “designed to fail” shite.
Posted on 3/7/24 at 9:25 am to LSUFanHouston
Insurance is kind of like the environmental impact studies that take ten years before highway construction begins. Take your premiums every month and then find every creative way under the sun to deny coverage.
Posted on 3/7/24 at 9:31 am 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.
In a perfect world. But in reality, the point when a consumer typically realizes they need this, they are at the counter to get the RX they are out of. And if it's heading into a weekend or a vacation? Yikes.
Posted on 3/7/24 at 9:35 am to concrete_tiger
quote:
In a perfect world. But in reality, the point when a consumer typically realizes they need this, they are at the counter to get the RX they are out of. And if it's heading into a weekend or a vacation? Yikes.
In 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.
If I am being prescribed medicine to deal with stress, it kinda counters the intent of the medicine if I stroke out trying to get my fricking meds.
Posted on 3/7/24 at 9:38 am to LSUFanHouston
What I don’t get is how an insurance company can refuse to cover a medication that your doctor believes you need. And I don’t understand prior authorization. If your doctor wrote you a prescription then it stands to reason he believes you need it. Why does the insurance company need additional info from the doctor? Maybe I don’t understand what prior authorization is but I do know it’s very inconvenient for the patient.
Posted on 3/7/24 at 9:41 am to EST
Some of the decisions are insane.
A recent example from my household is that insurance will only cover three months of Protonix (gastro meds for acid reflux, amongst other things) for an entire year. Doctor’s instructions are to use every day.
But they have no problems approving some other types of drugs of questionable need.
A recent example from my household is that insurance will only cover three months of Protonix (gastro meds for acid reflux, amongst other things) for an entire year. Doctor’s instructions are to use every day.
But they have no problems approving some other types of drugs of questionable need.
Posted on 3/7/24 at 9:42 am to SECdragonmaster
quote:
A pharmacist can fill any prescription that is written - unless it is Ivermectin and then they act like providers giving their opinion.
Pharmacists have recently been on my shite list. Tried to get a medication filled and they filled it, then wouldn't let me pick it up. It was an extended-release version of a med in the same class of a medication that I already take and it's also extended-release. I've had them fill it in the past without issue. The pharmacist told me she can't fill it and to switch to an immediate-release version, instead. I explain that the extended-release version is much smoother and has less side-effects for me and that they've filled it in the past, but she didn't give a shite. She didn't think that it was appropriate for me to be on two extended-release meds in the same class.
I'm thinking, "Bitch, if you wanted to be in charge of my health then you should have gone to med school. Just do your job and fill the prescription."
Pharmacists on power trips thinking they should get to play doctor are one of my ultimate pet-peeves.
This post was edited on 3/7/24 at 9:44 am
Posted on 3/7/24 at 10:01 am to Lawyered
quote:
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.
add in MTM, immunizations, the mandatory checking the PMP for every narcotic prescription, etc. and yeah, i don't miss pharmacy AT ALL!!!
Posted on 3/7/24 at 10:04 am to LSUFanHouston
I'm on a psoriasis medication that technically costs thousands a month. I worked with my doctor and got it at a heavily reduced amount of 25 dollars a month through the actual pharm company. My insurance tries at least once a year to jump in, and I've had to fight them consistently to stay out of it. Best case scenario they save me 300 a year, worst case I lose access to this medicine, easy choice.
Posted on 3/7/24 at 10:08 am to EST
quote:
how an insurance company can refuse to cover a medication that your doctor believes you need.
because it's privatized "for profit" healthcare...
oh wait, you aren't seriously thinking insurance companies work for the benefit of the people that pay for coverage, are you? insurance companies, as publicly traded companies, HAVE to work for the benefit of their shareholders and HAVE to strive to make a profit... one of the biggest ways to do that is to have very restrictive formularies and reject tons of claims...
Posted on 3/7/24 at 10:11 am to Jcorye1
quote:
got it at a heavily reduced amount of 25 dollars a month through the actual pharm company.
all you did was shift the costs to the other people that take the medicine.... you don't think the insurance company is going to, out of the goodness of their own heart, take that huge hit of lost profit, do you?
drug companies have BILLIONS of dollars to recoup for the R&D of the medication you are taking, and if they ain't getting it out of you, they'll simply shift that down the line... they ain't eating that cost, chief, i promise you that
Posted on 3/7/24 at 10:15 am to teke184
quote:
A recent example from my household is that insurance will only cover three months of Protonix (gastro meds for acid reflux, amongst other things) for an entire year. Doctor’s instructions are to use every day.
it's because chronic long term use of PPIs lead to bone density problems later in life, regardless of how much milk you drink, chief... they are trying to avoid a problem, before it is a problem, especially when you have a ton of other options for your tummy that are available out there
Posted on 3/7/24 at 10:20 am to teke184
quote:
It’s times like this I get pissed off that we had a system that worked MUCH better than got fricked over with the intention of transitioning us to socialized medicine.
The system wasn’t perfect but it was a lot better than this “designed to fail” shite.
it's not the "system" bruh...
it's the fact that we have developed so many drugs within that timeframe and drug companies are trying to recoup billions upon billions of dollars for that R&D... but insurances, as for profit, publicly traded commodities, are trying to earn money for their shareholders, so the more they have to pay for your high dollar, newly developed medication (that the drug company just developed and only has a certain amount of time left on their exclusive patent, before it goes generic and anyone can make, which decreases the cost of the drug), the less money they can claim as profit...
it's all very simple, when you boil it down....
This post was edited on 3/7/24 at 10:21 am
Posted on 3/7/24 at 10:22 am to chRxis
quote:
all you did was shift the costs to the other people that take the medicine.... you don't think the insurance company is going to, out of the goodness of their own heart, take that huge hit of lost profit, do you?
drug companies have BILLIONS of dollars to recoup for the R&D of the medication you are taking, and if they ain't getting it out of you, they'll simply shift that down the line... they ain't eating that cost, chief, i promise you that
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.
Posted on 3/7/24 at 10:28 am to concrete_tiger
quote:
In a perfect world. But in reality, the point when a consumer typically realizes they need this, they are at the counter to get the RX they are out of. And if it's heading into a weekend or a vacation? Yikes.
Oh, that happened to me a few times. Eventually I just started to put a reminder on my calendar that coincided with my last refill for a month to call my doctor and remind them to reup it.
It does suck when you're just starting a medication. I miss when docs could just go in their closet and pull out a few sample packs to get you going while you waited on your scrip to be approved.
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