Navigating the pre-authorization nightmare

The Pediatric Insider

© 2014 Roy Benaroch, MD

If the size of my stack of paperwork is any indication, 2014 will be the year of the pre-authorization. If you want coverage for a medication more expensive than aspirin, there’s a good chance it’s going to cost your doctors and their staff a mess of time and headache as they fight their way through flaming hoops of paperwork and phone trees.

Press 1 if you are a provider, press 2 if you elect to have red hot pokers jabbed into your eyeballs.

After a while, option 2 sounds better.

In a normal world, obtaining a prescription would work like this: you see your doctor, you share your concerns; a diagnosis is reached, and if a prescription is appropriate you discuss the pros/cons, the side effects, and anything else you need to know. Then you take your little piece of paper to the pharmacist, who gives you the pills. You pay your copay or whatever, and then continue with your life.

In 2014, there’s often an extra step. The pharmacist on her computer is told that a pre-auth is needed. Faxes fly between the pharmacist and doc, and we end up with multiple copies of a different form for every medication on earth, with all sorts of questions and little boxes to check off. Every drug has a different set of boxes, and — fun!! — we don’t know which boxes will get the drug covered. Even if we correctly get the boxes right, we’ll find out later that the medicine won’t be covered unless, say, the patient has already tried 2 drugs from group A and 1 drug from group Z (those come with an egg roll) for a minimum of 6 weeks, or 4 weeks in a leap year. And we have to send those records, and the egg roll, and a copy of the doctor’s organ donor card to the Lieutenant Governor (this is required to be sent by burro.) If the burro is late, we have to start over.

And, needless to say, half the time the insurance company will claim they didn’t get the fax. Or that the burro got lost. So we have to start over again. It’s like running a maze—except we’re blindfolded and don’t know where the walls are. And anytime the insurance company wants, they can send us back to the beginning at the crack of a whip.

Meanwhile: the patient waits. And fumes. And maybe says, “Forget it! I’ll just pay for the stupid medicine!”

Which means the insurance company wins.

Bonus for the insurance company: all of this makes the patient angry at the pharmacist and doctor, deflecting blame from their own oily “customer service” hides.

There are ways you can work together with your doctor and pharmacist to help fight this pre-auth nightmare:

Bring your formulary. There is a printed document (or a web-based database) from your specific insurance plan. It should show which meds are the least expensive, and It might indicate which medicines require a pre-auth. It might even spell out the conditions that must be met to get the pre-auth approved. Knowledge is power! Your doctor does not have this document, and we can’t keep track of all of the varying formularies for the multiple insurance plans we accept. Bring your own copy.

Choose generics when available. They’re usually covered, and usually safer than newer medications.

Sometimes, over-the-counter medications (and especially over-the-counter generics) can get you the same benefit as a prescription at a much lower net cost– give them a try.

Consider a “therapeutic substitution”, if your doctor agrees it’s a fair trade. Many, many medications have similar-enough knock-offs that are just as likely to work as any other medication. For example, all of these medications are essentially the same: Prilosec, Prevacid, Nexium, Aciphex, Protonix, and Nexium. And some of those even come OTC!

Remember: you will catch more flies with honey. Your pharmacist and physicians want to try to help you through this maze…. but this isn’t our fault, and blaming us by throwing a tantrum isn’t going to help get anything done. We are as frustrated as you are– probably even more, because we have a stack of these priors to get through every single day.

Take advantage of the NeedyMeds discount drug card. It’s free, it’s legit, and you may have a much lower payment with this card than with your own insurance. Ask the pharmacist to run your medications thru their computer on the Needymeds card instead of your insurance. You may be pleasantly surprised!

PS: A regular reader suggested I start putting in those “more after the break” lines, so more posts fit on my home page. What do you think? Keep the breaks? Go back to publishing each whole article on the front page?

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3 Comments on “Navigating the pre-authorization nightmare”

  1. Lisa R. Says:

    It’s easier for me if the whole article is in one place. Otherwise I have to go through a little rigamarole to be able to read the whole thing via my RSS feed reader.


  2. wzrd1 Says:

    We’ve had our battles with the insurance company as well. One difference is being highly proactive with the insurance company, ensuring the required step of burial of the quadruplicate forms being buried in a peat bog for six months, then lost twice, is omitted.
    Only once did I have to resort to harmful actions, where recalcitrance forced me to release an angry army of laser wielding ferrets into their office. Survivors, attempting escape found a mysteriously appearing moat surrounding the building, with my latest creation, electric sharks.
    They approved the thrice buried in a peat bog form and the local economy faced a boost, as many new workers were needed.


  3. wzrd1 Says:

    There is *one* pre-authorization that I am fond of.
    That of DNA, DNI or other matters on emergent medical conditions.


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