Thursday, January 19, 2017

The Successful Patient: Prior Authorizations

When I didn't need to go through the process of applying for new medical insurance this past December, I thought I'd have a quiet, smooth transition into the new year with my medical insurance. January, however, is the month for prior authorizations for medications. This year, my insurance company dropped three of my medications off its formulary of "accepted" medications. Last year, my doctor secured prior authorizations for two medications for me. The three are in addition to these two for a total of five medications for which I need a prior authorization.

What's a prior authorization or PA? It is the insurance company requiring an application for an exception to their formulary, or for a procedure or test that they don't normally cover. Sometimes, it's necessary to notify the insurance company before a surgery, hospitalization, or emergency room visit in order to get an approval to proceed and assurance that the insurance company will cover the cost. Someone at the insurance company reviews the application, looking for reasons that the medication is crucial for the patient's treatment, and based on that information, issues the decision to approve or deny coverage. Usually, the patient doesn't get involved in the process except to notify his doctor that a PA is needed for a specific drug or procedure. The doctor, or usually someone in her office, fills out the paperwork and submits it to the insurance company. The approval or denial will be sent to both the doctor and the patient. If denied, there is an appeal process that involves filling out more paperwork and submitting it.

I suspect that my experience as a patient is fairly common regarding PAs. Last November, I received notification from my insurance company that two of my medications would no longer be covered in 2017 and would need PAs. The two meds involved two different doctors. So, I called their offices, talked with their assistants and requested they submit PAs for the meds. I heard fairly quickly from one assistant who said the insurance company's response was that the med was covered. (We had decided to  wait with the second med.) So I called my insurance's customer service.

Dealing with customer service is always such a joy. I talked with a knowledgeable young woman that day who told me that my doctor's assistant had submitted the PA to the wrong place. So why wasn't the response to my doctor's assistant, "Sorry, you need to apply to this other place" instead of "The med is covered"? I did not say what I was thinking. I know about insurance company bureaucracy. It does not encourage independent thinking.  Anyway, the customer service rep told me that they'd instituted a new process for PAs, i.e. I could request them myself through customer service. So I did. For both of the meds. Pleased, I thought that'd be the end of it.


At the end of December, I received another notification from my insurance company. This time, they informed me that three more medications had been dropped from the drug formulary for 2017. One of the meds was my B12 that I must inject every 3 weeks for the rest of my life because my body can no longer absorb the B12 from food or oral supplements. That just astounded me. B12?  Really?  And I loved the bureaucratic, rationalizing language in the notice: "These changes help keep health care costs as low as possible for everyone, while continuing to make sure you have access to safe, affordable and effective prescriptions."

I called customer service. Did not get the same knowledgeable young woman I got the first time. This rep was as mystified as I was by the notification. She told me two of the three drugs, including the B12, were on the 2017 drug formulary and covered. The third drug was not -- this one I wasn't concerned about because I had enough at home to cover me for 9-12 months. I'll deal with it next year. So why was I sent this notification that was clearly in error about two of the drugs? Who knows. It just added to my irritation.

But then, during the same phone call, I asked about the PAs I'd submitted earlier in the month. Now they were supposed to communicate with me and my doctors about their decision, right? None of us had heard anything. The rep told me that for one, they needed more information, and my doctor needed to call their "Pharmacy Benefits Manager" which is an entirely different company they've hired to manage their pharmacy coverage. She gave me the phone number for my doctor. The second PA application wasn't in their system. Nowhere. Gone. So, I did another one right then and there -- this was the third PA application for this particular medication. Now I was beyond irritation.

After calling my doctor and giving her nurse the phone number for the Pharmacy Benefits Manager, I prepared myself for two denials. The first one came about three weeks later, apparently by phone -- I found an automated call informing me of the "denial for the medication" I'd submitted the PA for on my voice mail. Did not specify the medication so I didn't know which one it was for. I went to the Pharmacy Benefits Manager website, signed in, and went to the PA page. There, at the bottom, was my name and a notice for the denial for the drug that they'd requested more information about. That drug had an alternative that was on the formulary, but I hadn't been keen on changing. I talked with my doctor's nurse about it, and she suggested that the Pharmacy Benefits Manager wanted me to try the alternative before they'd approve the PA for the drug I'd been taking successfully for nine years. I gave in and have switched medications.

Oh, but the fun wasn't over!  No. Another call came 3 days later, same automated format that didn't specify the drug, and left on my voice mail. I figured it must be for the second drug, the one of the 3 PAs. This drug did not have an alternative on their formulary; in fact, this drug is unique and stands virtually alone for treating the condition I have. So, we'd have to fight the denial. But then, 24 hours later, another automated phone call came telling me that the PA had been approved for one year. Huh? I went to the Pharmacy Benefits Manager website and sure enough, there at the bottom of the PA page, under my name, were 3 notifications: one approval, and 2 denials (1 denial for the approved drug posted 24 hours before the approval).

All through the two months of this process, I had in the back of my mind the saying, "The left hand doesn't know what the right hand is doing." Insurance companies outsource functions and as a result risk inefficiency, errors, and in my opinion, a LOT of stupidity. Ah, but it doesn't even end there!

Today, I received in the mail two written notifications from yet another "Pharmacy Benefits Manager" company that had reviewed PAs for one of my meds that had a PA last year. The first notification, dated Jan. 12, informed me that the PA was approved for Jan. 5, 2017 to Jul. 3, 2017.  The second notification, dated Jan. 16, informed me that the PA was approved for Nov. 17, 2016 to May 15, 2017. So I guess this means that my insurance will cover this med from Nov. 17, 2016 to Jul. 3, 2017. This Pharmacy Benefits Manager company reviews certain drug "requests" to determine if they are "medically necessary." Really? How the hell can they determine that when they have never talked with me, don't know my complete medical history like my doctor does, and have not been in direct consultation with my doctor. And is it really a doctor in the same specialty working for this company that makes the determination?

That makes 2 Pharmacy Benefits Manager companies for the one medical insurance company. It's all a bureaucratic mystery.


Nancy/BLissed-Out Grandma said...

Just one of the reasons health care costs are so high. Sheesh, what you describe is enough to make a person even sicker!

Gina said...

Just to top it off, Nancy/Blissed-Out Grandma, the one med my insurance company wanted me to switch to on their formulary is making me sick! I started it today at a very low dose to do an increasing taper over a month. Two hours later, severe nausea, severe lightheadedness to the point of thinking I'm going to pass out, constant hot flash, and increased pulse. I had to call in sick to work. And now it's afternoon, and I'm still having the side effects although not as severe. I called my doc and talked with her nurse. I asked if these side effects would continue, and if so, then I had a big problem with this med. Not going to call in sick again because of it. And the med my insurance company made me give up because they denied the PA? I'd taken it for 8.5 years without any problems and it was working wonderfully. Go figure.