Prior Authorization

This is a a term, unfortunately, that we are all becoming for familiar with.  If you are on a long- term medication, you may have received a letter from your insurance company, telling you that this year, there is a possibility that your medication may be substituted for one that is “similar”, assure you that this is fine for you medically, however if your health care provider feels stronger that you should stay on your original medication, they can write to the insurance company and get it changed.  Sounds easy, right wrong. It is a nightmare, time consuming, and the providers office typically loses money getting this done.

Since we all learn better with examples, here is one.  A patient of mine with numerous co-morbidities, has had atrial fibrillation for more than twenty years.  We know that one of the significant side effects of a fib is a stroke, a potentially life- threatening event.  We also know that we can hopefully prevent strokes, particularly with in patients with a fib.  At 65, my client was started on Eliquis, a relatively new medication to the drug armament that is used to prevent patients with a fib from developing a clot, which can then break off and go to the brain.  The other two medications recommended by the insurance company (not the prescribing physician) were Zarelto and warfarin (an old medication for those with risks for strokes, but has to be monitored with regularly blood tests to be sure their “level” is therapeutic; (if too “thin” risk of bleeding increases” if not thin increases risk of stroke. The problem with warfarin is multi fold, certain foods (ie salads) can affect it, medications, illnesses.  Zarelto is also used, but the side effect is slightly increased bleeding, more so than with Eliquis. 

I knew my client’s cardiology practice, so I started the ground work. They filled out the initial paper work, and the last question was “are they allergic to Zarelto or to warfarin”, don’t know, never tried, second questions, “what else have they tried?” There is no place on the form to enter any important information, so you start the waiting game.   Insurance companies do this because they have made a lucrative deal with the manufacturer, and it is is their best interest to give you a different medication, which may or may not be the correct medication for you.  No surprise, it was denied. 

Fortunately, the nurse practitioner in cardiologist’s office was beyond awesome, and willing to work with me and the insurance company. Long story short, you need to have two denials (the questionnaire) and then, and only then, will they proceed.  This involves a letter, along with documentation as to why the client cannot (or should not) change medication.  I found documentation as to why Eliquis was a better choice (my client has had three incidents of bleeding), wrote a letter with this attachment and sent it to the nurse practitioner.  She “cleaned it up,” brought it to the doctor to sign, and sent it off with the word “URGENT”.  Apparently, if written urgent, they will get to it in three days, if not 30 business days, how appalling is that?  Needless to say, it was approved, but why should we have to jump through hoops like this?  And how many offices are willing to do this?  We were recently with a cardiologist friend, and his attitude is that, he “has no time” and won’t do it.”   So here we have it, be your own advocate, and when you have problems (as many of us do) contact a professional.  The cost is a lot less than you think, and you will sleep better at night.

#beinchargeofyourhealth.  #nobodymattersmorethanyoudo.  #healthadvocatesarethebest