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Getting Around Pharmacy Prior Authorizations

Updated on June 1, 2011

Name Brand Meds Requiring Priors

Clockwise from top: Singulair, Lexapro, Norel SR.  All three are available only as a name brand product and all three frequently require prior authorizations.
Clockwise from top: Singulair, Lexapro, Norel SR. All three are available only as a name brand product and all three frequently require prior authorizations. | Source

One of the great mysteries to the patients that I serve on a daily basis is that of the pharmacy prior authorization. The process is long, aggravating, and entirely ambiguous. It never seems clear what the patient needs to do, what their doctor needs to do, or what the pharmacy intends to do. To better understand this process, let us invent a new patient and follow her through the steps of filling a prescription for Lexapro.

Step 1:

Andrea drops off her prescription and then leaves the pharmacy foyer to shop for groceries. Forty minutes later, she goes back to the pharmacy where she waits in line at the pickup window for, say, ten minutes.

Step 2:

Andrea is dismayed to find that, after nearly an hour long wait, her pharmacy has not filled her prescription. They claim that the prescription needs to be “authorized” or something. Andrea’s mind is saying, isn’t having the prescription authorization enough? The answer to Andrea’s question lies hidden in the mire of tasks that her pharmacy perform daily that don’t even occur to Andrea.

Let’s re-examine the situation from my perspective, as a pharmacy technician.

Step 1:

Andrea drops her order off and I scan her prescription hard copy into the system and then begin typing the drug, strength, quantity, directions, date, and doctor.

Step 2:

Having completed the necessary data entry I attempt to submit an electronic claim to her insurance company. They reject my claim saying, “Prerequisite Therapy/Prior Authorization Req.” I roll my eyes in frustration at yet another rejected claim.

Step 3:

A fax is sent to the appropriate doctor’s office detailing the fact that Andrea’s insurance does not prefer to cover Lexapro and if her doctor insists that she take it, then he must send the insurance proof that she has tried and failed on other selective serotonin reuptake inhibitors (SSRIs) like Celexa (which has a generic).

Step 4:

Waiting…a secondary fax is sent…a phone call is made…

Over the course of several days (or sometimes several months), the doctor attempts to battle it out with Andrea’s insurance company to convince them of her need for this particular medication.

Insurance companies have designed the prior authorization process to protect their assets. If patients die or give up on attempting to fill expensive medications, then insurance companies come out ahead. This makes the CEOs of big insurance companies happy (because their bonus check will be large), but makes patients in need of care extremely angry.

But why doesn’t your insurance just cover anything the doctor orders? The answer to that question is simple. It can probably be best summed up in the words of one of my co-workers: “there is ideal medicine, and there is adequate medicine.” Ideal medicine describes those expensive products which insurance companies say require a prior authorization. The medications are the best at what they do, they are the most up to date and most effective out there. And their prices correspond to their results. Adequate medicine on the other hand, describes drugs that have been around for some time, have been proven to work, though perhaps not quite as well as the newer therapies, and that cost far less. An example of such a dichotomy would include Avelox vs. ciprofloxacin. Both are quinolone antibiotics, both can treat the same types of infections, but the former costs a small fortune for a ten day course.

That is why insurance companies require prior authorizations. They don’t want to spend $190 on an antibiotic for your strep infection. They want the cheap stuff. The cheaper you have to go on drug costs the greater their profit margin is. It all comes down to money and your pharmacy and doctor have very little power in the overall scheme of things. The insurance companies of today have transformed “healthcare” into an ugly beast that has simply reinstituted Darwin’s theory that only the fittest (or richest) can survive.

This does not mean that you should lose hope, however. There are certain disease states for which expensive, brand name medications are necessary. Insurance companies fear lawsuits (though they would never admit it) and if a patient’s life truly does hang in the balance, priors are usually a fleeting thing. In the case less life-threatening condition, it may be best to call your insurance and find out what their prerequisite therapies are. You may as well try such therapies since you will not get a prior without having failed the frontline therapy first. And who knows, it could end up saving you money (and headache) if you simply have your doctor switch medications.

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