Patients

Prior Authorizations: Will They Become Damocles Sword?

By NIRAN AL-AGBA MF, FAAP

In July 2009, the family of Massachusetts teenager Yarushka Rivera went to their local Walgreens to pick up Topomax, an anti-seizure drug that had been keeping her epilepsy in check for years. Rivera had insurance coverage through MassHealth, the state’s Medicaid insurance program for low-income children, and never ran into obstacles obtaining this life-saving medication. But in July of 2009, she turned 19, and when, shortly after her birthday, her family went to pick up the medicine, the pharmacist told them they’d either have to shell out $399.99 to purchase Topomax out-of-pocket or obtain a so-called “prior authorization” in order to have the prescription filled.

Prior authorizations, or PAs as they are often referred to, are bureaucratic hoops that insurance companies require doctors to jump through before pharmacists can fulfill prescriptions for certain drugs. Basically, they boil down to yet another risky cost-cutting measure created by insurance companies, in keeping with their tried-and-true penny-pinching logic: The more hurdles the insurance companies places between patients and their care, the more people who will give up along the way, and the better the insurers’ bottom line.

PAs have been a fixture of our health care system for a while, but the number of drugs that require one seems to be escalating exponentially. Insurance companies claim that PAs are fast and easy. They say pharmacists can electronically forward physicians the necessary paperwork with the click of a mouse, and that doctors shouldn’t need more than 10 minutes to complete the approval process.

But in my experience, that’s rarely the case. In order to get my patients the drugs they need, I regularly spend more than half an hour on the phone with ill-trained customer service reps who don’t know the first thing about pharmaceuticals and whose job description consists of being as obstructionist as possible.

And I’m not alone. A video by an independent physician with a sense of humor documented his Kafka-esque bid to obtain a PA for a patient. The video lasts 21 agonizing minutes. And studies have shown that PAs gobble up at least 20 hours per week in the average physician’s office. Even in an age when many aspects of practicing medicine in the United State have become nightmarish, PAs hold a place of particular sinister distinction.

Now, back to the Rivera case in Massachusetts. After Walgreens declined to fill Yarushka’s Topomax prescription, her family returned to the pharmacy four more times –each time without success. (It’s unclear whether or not Walgreens ever actually sent an authorization request to the physician’s office.)

Without the drug she’d relied on for years, Yarushka had three seizures. The last one proved fatal.

Her grief-stricken family subsequently filed a wrongful death suit –not, as might be expected, against the insurance company that required the PA in the first place, but rather against Walgreens, Yarushka’s physician and his practice.

To my mind, this case gets it all wrong, and in so doing, potentially dangles Damocles’ sword over the heads of each and every physician and pharmacist practicing in the United States today. The fact is that both Yarushka’s doctor and the Walgreens pharmacist did their jobs: Her physician issued a prescription for the life-saving anti-seizure drug, and the pharmacist tried to dispense the medication. It was Yarushka’s insurance company –not the physician or the pharmacist- that was the monkey wrench, arbitrarily denying coverage for her medication without any reasonable justification.

Medical malpractice is defined as negligence by act or omission in cases where the prescribed treatment fell below the accepted standard of practice and caused injury or death. In the Rivera case, MassHealth alone created the barrier between Ms. Yarushka and her life-sustaining medication.  The insurance company was, effectively, practicing medicine without a license. And it alone should be held accountable for the tragically predictable outcome after overriding the sound judgment of her physician and pharmacist.

But because of a legal doctrine called sovereign immunity, which shields states from civil or criminal prosecution, it’s highly unlikely that MassHealth, a state-run insurer, will ever face legal consequences Yarushka’s –or any other, for that matter.  How many more patients have to die before we force insurers to prioritize patients over profit?

The Rivera case is still winding its way through the court system in Massachusetts, but a verdict against Walgreens will open a Pandora’s box for medical professionals across the country, effectively holding them legally liable for the decisions and practices of an all-powerful third party that’s under no obligation to follow their medical recommendations.  If MassHealth is not held accountable for causing the wrongful death of Yarushka Rivera, then more insurers will be emboldened to practice medicine without a license, which will surely lead to the deaths of countless other patients nationwide.

Niran Al-Agba (@silverdalepeds) is a third-generation primary care physician in solo practice in an underserved area in Washington State who blogs at peds-mommydoc.blogspot.com.

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29 replies »

  1. I realize I am a little late to the game, but I am here. 🙂

    From a patient’s perspective, I cannot hold my pharmacy or my physician (or other providers) responsible for something invented by and installed by insurance companies. That would be the same as blaming my cell phone provider because my trash was not collected. Yes, I used my cell phone to call and initiate trash collection service. But what does that have to do with the price of eggs in China? (I know, it should be rice… thank my mother for that.)

    I am an insulin controlled diabetic. I also have IBS-D. Plus several other chronic conditions including pernicious anemia. I think all of you can imagine the ordeal in getting the insulin types my doctor ordered. His RX accounted for my other medications and conditions. The PBM, CVS/Caremark, gave me hell in trying to get the type and quantity ordered by the doctor. CVS wanted me to try less expensive types of insulin that my physician, an internist, had ruled out. He did not rule them out in a vacuum, as I have a huge advocate of the ONLY person 100% responsible for my healthcare, treatments, medications, and errors regarding those is ME. Ask the nurses when I am in the hospital. I keep track of everything and have the last word on how much insulin I am given. (Hypo-g is no joke. I know how my body changes when I am sick and how that changes my ratios.)

    So blaming the pharmacy is the wrong target. However, the pharmacy has a duty to let the patient know when the insurance company disallows a medication because it requires a PA. Most large pharmacies have software that, with the click of a mouse, sends a PA notice to the physician via fax or electronic means. In my experience, this is where there is a fault in the communications. Neither the pharmacy nor the doctor notifies the patient that a PA is needed, or if it is denied. I find out a day or three later when I look online to see if my meds are ready – at least for refills.

    This week started another PA horror story for me. My doctor and I discovered that the idiopathic nausea/retching that I have had since a Nissen Fundoplication followed weeks later by an emergency cholecystectomy in 1997, was very treatable with Ondanestron (Zofran) 8mg ODT. This was after trying many of the antiemetics. I actually discovered how effective it was through a chance encounter with a doctor (gastroenterologist) at a week long winter Scout camp. He witnessed me retching and checked to see if I was OK. After the episode passed, he told me his specialty. [Free consult!] At the time I was using Promethazine 25mg TID. He offered me some sample Zofran tablets after we discussed a medical history and other medications. I began taking one of those at the onset of nausea, which was >75% of the time after a meal. By the end of next day I had not had any retching. In the middle of the second day, I bypassed nausea and went right to retching. He came prepared, and with my consent, injected Ondanestron 4mg/2ml IM. After a couple of minutes, it all stopped. This happened one more time before the camp ended. I also mentioned that the IBS-D symptoms went from 0% controlled to 50%, and he said that a study was underway at the time looking at Zofran as a viable treatment option. He explained that in most people it causes constipation. Since 1997, I had an extensive work up for nausea/retching and diagnosing IBS-D. I was prescribed one antidiarrheal after another with little relief. I had also gone in 90-day avoidance diets of various food types. (AKA torture, especially combined with a series of repeat -oscopies during a 3 year period.)

    After getting home, I spoke to my doctor about the effectiveness of Ondanestron. Being me, I had already checked my plan’s formulary and neither Zofran or Ondanestron were present. So, we began with 4mg PRN after meals. Not so effective after a month, so up to 8mg PRN after meals. Oftentimes, I had to refill the 60 tablets prescribed before the end of the month. Then near the end of 2014, the Scout gastroenterologist sent me a link to the study results. I forwarded that to my doctor and started getting 90 tablets per month. At about the same time I asked about getting the injectable for use with retching. Over time we discovered that 10 vials would cover me for 30 to 45 days.

    Fast forward and in 2018, my insurance added all forms of Ondanestron to its formulary with approval only for 36 tablets per month post surgical, required chemotherapy, or radiation therapy. Last week, I submitted my refill requests and never received the text or email that my prescription was ready. I called the pharmacy on Tuesday and began the PA marathon. I spoke to the doctor’s office, the PA had been submitted and denied. They submitted the first line appeal and it was denied. NOBODY bothered to tell me.

    Now I call CVS. I get the robo-like reply that Zofran is not medically necessary unless one of these three requirements is applicable. I have a quick wit, and a strange sense of humor, so I said, “Well, I *am* post operative.” The rep asked what surgery and when. “Nissen Fundoplication and gall bladder, July 1997 and September 1997 respectively.” I was told, “Sir, the surgeries must be recent.” By now I have located the PA form the physician completes and I point out that the form simply says post operative, it does *not* say how long ago. I was getting nowhere, so I asked to escalate. I was transferred to a senior rep. We go through the entire spiel again. Then I ask, “Looking at the PA request form, there is a check box with the word ‘other’ beside it and a blank line. If the only way you will approve this is for those three reasons, why is that there?” Silence, followed by, “That is a good question.” (Yeah, I know. They are the only kind I ask.) So then she goes into the process I must now follow to establish a medical necessity. I interrupt her with another question, “What is that little slip of paper the doctor uses to write a drug name, strength, directions, quantity, and directions?” Long pause. She asks if I mean a prescription form. BINGO! “Yes, ma’am. Correct me if I am wrong, but it is my understanding that federal and state laws, as well as the standards of practice, require a physician to examine a patient, form a decision as to diagnosis, and using his best medical judgement based on education, training, and experience, establish a treatment plan based on the medical necessity of the patient. Only then can he ethically snd legally prescribe a medication. Is that true or false?” She starts off into some explanation about internal policies and I cut her off, “Ma’am, that information sounds fascinating. But, please answer the question I asked and not the one you wanted me to ask.” Of course she said it was true. So I further enquired, “So, by the overt act of writing the prescription, the physician has established a medical necessity, correct? Yes it no, please.” Of course she said yes. “Thank you, you are entering the override now for both 90 tablets and 10 vials, correct?” Of course not.

    I was quiet. Counting to ten several times takes a bit. Then I asked, “What specific medical training does the person who denied this PA have? In what state or states is that person licensed to practice medicine? What is the person’s name and NPI number?” She tells me that a “highly trained” review specialist made the decision, not a doctor. “Oh, so they are a licensed pharmacist? Great. Name and NPI?” They are not pharmacists.

    Then she tells me that I need to write a letter that explains the medical necessity, gather copies of clinical notes, medical records, lab results, imaging results, and a letter from my doctor listing all of the other medications attempted and the result for each. Then mail that packet to them for reconsideration. It will take 21 to 30 days to process and provide an answer.

    I was quiet. Counting to twenty several times takes a bit. Then I exclaimed, “Oh, hell no! I will be out of tablets by Saturday and I have one vial remaining. Now you are telling me that I am going to have to resort to painful retching, feeling nauseated, and lose any control over my IBS-D? All over some stupid arbitrary rule for a medication that I have taken for over four years and WORKS?! You are not denying it over cost as the total cost it the vials is less than $30 and the total on 90 tablets is less than $70, of which I pay 20%. Speaking of paying, my monthly premium is $243 that I pay, and my retirement pays $499, for a total of $742. I have Medicare A and B, so my insurance pays very little of my medical care. I only pay the premium to have drug coverage. So, hell, no! Put the CEO on the line. Do not tell me you cannot. Just get someone on the phone who is not going to practice medicine without a license, who is not interfering with my doctor patient dynamic, who is not giving pharmaceutical advice without a license, and who has the balls to say ‘yes!’ I will wait, do not speak. Just transfer me.”

    A few minutes later a patient care specialist came on the line. She called me yesterday, Thursday, to let me know the PA had been approved. By closing time last night, the pharmacy was still unable to process the prescription. The specialist did tell me it was possible that it would take until today.

    One it processes, I am sending them a letter requesting compensation at my equivalent hourly rate as adjusted since retirement in 1999. According to my phone, I spent: 20 minutes speaking to the pharmacy; 15 minutes speaking to the doctor’s office; 10 minutes checking online to see if medications were ready; and 3 hours and 26 minutes on the phone with CVS. That is 4.2 hours at $35, or $147.

    Then I am going to calculate the increase in the amount of insulin caused by all of that by comparing the average daily amount for two weeks ago to this week. That is an average increase of 16 units per day, or 112 units for the week. (wow!) Each unit is $136.00.

    I am also going to have a line item charge for the intentional and wanton infliction of anger, frustration, anxiety, fear, and other emotions. I think treble damages is appropriate.

    $ 147.00 Time Wasted
    $ 136.00 Insulin Use Increase

    $ 283.00 Actual Damages
    $ 849.00 Wanton Infliction Stress

    $1132.00 Total Damage

    Then I need to compensate the doctor, his nurse, the pharmacist, and pharmacy tech, none of whom were paid for any part in the denial/PA process. Just for S&G’s, I think 1 hour is a fair estimation of time each spent dealing with this. The average hourly rate for an internal medicine doctor is $96 and a pharmacist is $59.

    $1132.00 For Me
    $ 96.00 Physician
    $ 35.00 Phone RN
    $ 59.00 Pharmacist
    $ 16.00 Pharmacy Tech
    $1338.00 Total Reimbursement

    Total annual amount the insurance pays for both of the denied PA meds combined is $80. Yearly, that works out to: ($80 × 12) = $960

    $960 vs $1338, and how do PA’s reduce costs? This does not include the value of time CVS spent on the phone with me, the doctor, or working internally to address the issue.

    Maybe it is cheaper just to pay the claim.

    My apologies for the length. 🙂 My opinions are detailed.

  2. Dr. Morgan…. YES! This exactly. You nailed the point of this post perfectly. Here we are with no authority, no control over basic scientific decision making, and basically doing the work for free of prior authorizations — and now, we can be sued for something we did not create. I think all offices should have a “No PA policy” to protect us and then if we think a certain med is necessary we can CHOOSE to do the PA without liability if it is rejected.

  3. Fair enough, Barry. For what it is worth, that is the larger point of this post: holding the pharmacy or physician responsible for a medical decision they did not make is ridiculous and will scare a lot of physicians away.

  4. Could you make a reasonable living if you had to accept Medicare rates from all comers?

    If Medicare pays too quickly and too easily with little or no oversight, it increases the risk of fraud which has long been a significant problem. As a taxpayer, that’s a concern to me.

    I assume you know there is no such thing as a straight Medicare Part D drug plan. All Part D plans are private plans. Some are part of a Medicare Advantage plan called an MAPD plan while others are stand-alone Part D plans.

    After 6 1/2 half years on straight Medicare, I’ve only had one drug require PA — Eliquis. As noted previously, the insurer required PA because it wants as many afib patients on Coumadin as possible if Coumadin is good enough for their disease status. A 30 day supply of Coumadin is $4 at Walmart whereas.30 days of Eliquis is $424 at most drug stores in my area. That’s a pretty significant cost difference. Isn’t it?

    If MA plans are so difficult to deal with then don’t accept them and tell them why you won’t accept them. If enough doctors do that, insurers will presumably get the message and become more user friendly for both patients and doctors though they may have to raise their premiums somewhat.

  5. Straight Medicare is great in terms of the low hassle level; Medicare Advantage plans generally are the worst of all, with lots of pre-auths required for generic drugs. I tend to avoid them.

    Anyway, the RVU system was designed before 2 hour pre-auths were common.

    And, as Dr. Al-Agba indicates, pre-auths frequently come out of the blue unconnected to an office visit or procedure, so you’re talking about 44% of zero RVUs which comes to . . .

    But, patients are entitled and expect all this for free.

  6. My about to retire cardiologist told me that about 50% of his time in recent years is spent on things other than direct patient care. This includes everything from reviewing reports from hospitals, imaging centers, labs and specialists to fighting with drug companies and insurers including dealing with pre-authorization requests.

    You may not be aware but Princeton’s late health economist, Uwe Reinhardt, told us that the value of a Medicare relative value unit breaks down as follows: 52% covers the physician’s skill and technical effort, 44% covers practice overhead, and 4% is attributable to malpractice insurance. In other words, there are a lot of hassles that come with the territory of being a doctor in the U.S. which are particularly onerous for primary care doctors. I doubt that even a Medicare for all system would provide much relief which would probably wind up being Medicare Advantage for all in any case.

  7. It makes no sense to me to hold physicians or pharmacists accountable for a rejected or unreasonably delayed pre-authorization decision by an insurance company or PBM.

    More broadly, I think we are one of the most litigious societies in the world if not THE most litigious. Physician practice patterns must take that cultural reality into account and is one of the big reasons, in my opinion, for why healthcare costs are significantly higher here than in other developed countries. There is way too much defensive medicine delivered out of necessity. To be clear, I don’t blame doctors for that either. I blame the American citizenry for our litigious culture.

  8. “Maybe it’s time for doctors, hospitals, drug companies, insurers, employers and PBM’s to stop talking past each other and try to find some solutions”

    If it is taken as a given that everyone is fairly paid for their work, great.

    If it’s assumed that physicians have to work for free in order for the pre-auth process to function, don’t bother.

    You seem to be unwilling to agree that physicians should be paid for their work doing pre-auth. I don’t understand that.

  9. Physicians have no contracts with PBMs, have never been given instruction on what they expected to do or how to do, have no authority to reverse any bad decisions made by others, and are not paid for their work – yet, apparently, they can now be sued for anything that goes wrong in the pre-auth process.

    Chilling.

  10. First of all, many physicians including myself have spoken with members of Congress about healthcare. They don’t understand it any better than you or other laypeople do. As for what I’m implying, you have it completely backwards. I am making the point that physicians should not be held accountable for negligent acts on behalf of the health insurance company. The insurance company should be legally responsible for this death. Not the pharmacy and not the physician. PAs for New or extremely expensive medications certainly makes sense when there are suitable cheaper alternatives.

  11. The CEO compensation and education line makes for a nice liberal sound bite but even if the 25 most highly paid executives of every insurance company all worked for free and the savings were used to reduce insurance premiums, the price reduction would be a small fraction of 1%. United’s revenue will be north of $200 billion in 2018. Moreover, United’s premiums are competitive with those of the non-profit Blues where executives are paid a lot less because there are no stock options and RSU’s to award as non-profit entities.

    I didn’t say that primary care doctors are a big part of healthcare costs. They aren’t. However, people get sick and are involved in accidents even with excellent primary care and sensible lifestyles. Hospitals have to operate around the clock. Urgent care centers are open many more hours per week than the typical primary care practice. New lifesaving drugs are very expensive to develop and there are plenty of failures along the way. Every piece of the system needs to cover its costs including the cost of capital to survive.

    Yes the case in your post is a sad story that didn’t have to happen but you imply that PA shouldn’t exist as a result. The payer screwed up in this case but costs would be a lot higher if payers had to pay for everything and anything that a doctor ordered without question. If you can design a better system that won’t cripple medical innovation, let your congressman and senators know about it.

  12. “reasonable balance sheet”: Stephen Hemsley annual income 2014 $66 million, Niran Al-Agba, MD 2014 $89,000. You are right Barry. Doctors are totally unreasonable.

    Years of education: Stephen Hemsley 4 year bachelor degree. Dr. Al-Agba 4 year bachelor, 4 year for MD, and 3 years of pediatric residency (annual income average $22,000 during those 3 years.)

    CEO’s direct “culture” of the organization: Dr. Al-Agba does CPR on a 10 day old baby in her clinic while waiting for an ambulance to arrive. Child survives and was admitted to a children’s hospital ICU. $70 bill is rejected by United Health Group because 10 day old was “assigned” to adult nephrologist “by accident” for primary care in a different county.

    Parents willing to pay $70 out-of-pocket to compensate physician. Stephen Hemsley sends note threatening to sue said physician charging for an office visit United Health Group refused to pay.

    Compared to the local ER and urgent care, I am 1/10 and 1/5th the price of those clinics on average. You seriously believe primary care physicians are the problem?

    Healthcare isn’t actually expensive in reality. 90% of what we do is simple and affordable. But PBMs, Hospitals, Urgent Care clinics, Big Pharma, and insurers need their cut. They would kill one another just to grab those last dollars.

    Oh, wait, that is what this post is about in the first place. An insurer who let a 19 year old woman die rather than cover her $399/mo anti-seizure medication, for which there is no substitute.

    Seriously, if this story doesn’t grab your heart, then nothing ever will. Her death literally did NOT have to happen.

  13. You summed it up perfectly. “It doesn’t cost them a penny to keep a doc on hold for 30 minutes.”

  14. Another view of the PAs is that they exist as a result of the provider agreements principally originating between the insurance companies and the Complex Healthcare Providers, aka tertiary medical centers. The irony, of course, is that they have never exhibited a vested interest in the affairs occurring at the front-lines of healthcare. Any carrier tries to maximize its profit margin in spite of the annual increases in reimbursement requested by the Complex Healthcare institutions. It is most precisely defined as a very large institutionally co-dependent relationship. No wonder they are unable to exhibit autonomy in behalf of their constituent’s HEALTH. The loss of autonomy among the carriers and tertiary medical centers drives the annual increase in our nation’s health spending as a portion of our national economy (GDP).

  15. Doctors persist in claiming that insurers just care about profits while insurers say that doctors just want to be left alone to practice medicine as they see fit, they want their bills paid quickly and without question and they want their prescriptions filled without any hassle for their patients or themselves. Both patients and employers complain loudly and often about the high and rising cost of health insurance. Of course, health insurance is expensive because healthcare is expensive.

    A reasonable balance needs to be struck here since money is the constraining resource and we’re already spending close to 18% of GDP on healthcare. Maybe it’s time for doctors, hospitals, drug companies, insurers, employers and PBM’s to stop talking past each other and try to find some solutions. Unfortunately, some of the most significant cost drivers are cultural and won’t be easy to change.

  16. ‘there is room for improvement in the process of getting pre-authorizations approved so it doesn’t consume as much physician time”

    Sure there is, but it won’t happen – it will only get worrse. Why would PBMs invest in more staff and equipment – it’s doesn’t cost them a penny to keep a doc on hold for 30 minutes.

    “self-funded employers and insurance companies would not hire PBM’s to manage their drug benefit if it didn’t save them a significant amount of money”

    And a significant part of those savings are achieved through the free labor of doctors and their staffs, labor which makes them less available to their patients. That doesn’t bother you?

  17. Have to agree that the use of pre-authorizations seems pretty indiscriminate and aimed at saving money for the insurance company, regardless of the necessity of the medication or procedure. Also, this is something to remember when we talk about administrative costs in medicine. Admin cost estimates often do not include the costs on the provider side. There are substantial costs incurred with PAs and even just following different billing rules when dealing with the different insurance companies. Miss a rule change sent out by the insurance company and it can cost you big bucks. (True experience, not conjecture.)

    Steve

  18. We should be compensated for our time. Can you imagine a lawyer doing a PA for free? It would never happen. There was a physician who successfully sued the insurance to be paid for his time. Some physicians are charging patients for the time spent doing prior authorizations. Primary care physicians have families to support too, just like everyone else.

  19. Dr. Holm is correct. Withdrawing people who are stable on seizure medicine is medical malpractice and insurance companies (who are choosing to do this to save $$$) should be held responsible.

  20. Barry, I am so glad you asked what I see as THE most important question about this entire sad situation. No, there is no alternative to Topomax . Seizure drugs in children are more of a precise science than say Afib (sorry). One drug may work for one person and another may not prevent seizures even if the two children have similar types of seizure disorders. This was a $400 drug and absolutely tragic results.

    To address your other question… I did not say PA’s should not exist. However, to withhold a medication that has been on the market since 1996, is very short-sighted. BTW, Insurance premiums should not be your first thought when we are discussing covering a life-saving medication for a 19 year old.

    You must be joking about this: “Don’t you think doctors are involved in establishing the formulary and individual drug restrictions in the first place?” Don’t be ridiculous. If practicing physicians were involved, PA requirements for life-saving medications for which there is no alternative would simply not exist. All primary care physicians know how important life-sustaining medications are for young adults. We would never play with fire. This was solely an insurance decision, which is why I am writing about their liability in this situation.

    An example of PA’s in practice are like this… a patient needs a steroid inhaler for asthma. I don’t care if they use Flovent, Pulmicort or Qvar, whatever is on formulary is fine. One day a year ago, 24 patients on same insurance are on Flovent and I get a dozen PA requests because the insurance formulary changed to preferring Qvar. Now, I can do PA’s which will take at least 40 hours for two dozen patients or issue new prescriptions for Qvar to be “complaint” with this weeks choice of drug for said insurance. What a waste of time.

  21. Actually Dr. Morgan, the Supreme Court in Mass just ruled that indeed the lawsuit against Walgreens CAN go forward for not following up on the PA request. It appears the mental health facility part is a completely separate legal action from what I can tell.

  22. It was a clear conflict of interest for Medco to be owned by a drug company (Merck) so it was eventually acquired by Express Scripts. Express Scripts is about to be acquired by Cigna.

    While I’m sure there is room for improvement in the process of getting pre-authorizations approved so it doesn’t consume as much physician time, I can guarantee you that self-funded employers and insurance companies would not hire PBM’s to manage their drug benefit if it didn’t save them a significant amount of money vs. what it would cost to manage it themselves. That’s why we have formularies, tiered copays, pre-authorization and quantity limits.

  23. My doctor explained to me that there are three levels of afib — occasional, paroxysmal, and persistent / sustained. Mine was persistent and he thought one of the newer drugs was best for me. A relative of mine has occasional afib and has been doing fine on Coumadin for the last 12 years. A 30 day supply of Eliquis costs 106 times as much as a 30 day supply of Coumadin based on Walmart’s price of $4.00 for Coumadin. Even if the newer drugs are somewhat better, how many people would we have to treat to avoid one stoke event and is it cost-effective? Moreover, until recently at least, there was no reversal agent for Eliquis whereas there is one for Coumadin.

  24. This sad story seems to be quite complicated. Apparently, the patient was out of Topomax for at least two months, during which time she was hospitalized at least once for a seizure and discharged with a Topomax rx that wasn’t filled. She suffered her fatal seizure while at a mental health facility (not clear if inpatient or outpatient); they are being sued by the family for having unlicensed staff, but not, it seems, for not giving her Topomax.

    Very sad.

  25. If you got Eliquis anyway, what exactly was the point of the PA? The only thing it accomplished was punishing your physician and undermining their practice. You also understand that some of the NOACs are demonstrating superiority and safety above Coumadin in certain studies.

    There are some categories of medications that contain apples and apples, certain blood pressure medications for instance. Neuroleptics are not one of those categories. People who are on a stable seizure medication under control need to be left alone. There is the potential for harm when switching medications and it should not be taken lightly.

  26. Anecdote: back when Merck owned one of the first big PBMs, they were causing incredible chaos for doctors, patients, and pharmacists in our area. Working up the phone tree, I got hold of a regional manager of some sort and said that along with other doctors in the area, I would pay my staff to meet with a rep from their company and learn how to use their system. Or if that wasn’t possible, how about sending us some printed guidelines with accurate phone numbers. Her response to both proposals was a blunt “No – we don’t consider that a good use of our time and resources.”

    Well, from that great beginning, things have gone downhill precipitously. It is not uncommon for a pre-auth to require two hours of time on our part, at least 50% of which is time spent on hold. The phone number is always wrong and you’re connected to someone else who takes all the same information and then gives you another wrong number and on and on . . .

    The solution is very simple. If the pre-auth is both necessary and appropriate, the PBM should pay the physician market rate for their time. Unnecessary pre-auths would disappear and they would make sure that the process is efficient.

    That’s the only language these parasites understand.

  27. This is a sad case to be sure but are you suggesting that prior authorization is NEVER appropriate and shouldn’t exist? What about quantity limits on certain drugs; are they wrong too? Insurance premiums would go through the roof if payers had to pay for every service, test, procedure or drug without question. Don’t you think doctors are involved in establishing the formulary and individual drug restrictions in the first place?

    When I developed atrial fibrillation in 2015, I was prescribed Eliquis but it required prior authorization. my doctor had to jump through some hoops to get it approved for me but I got it in the end. The reason that insurers require prior authorization for Eliquis, Xarelto and Pradaxa is because they want patients to try Coumadin instead which is very inexpensive though it comes with some dietary restrictions and requires periodic INR testing.

    Weren’t there any other drugs in the same therapeutic class as Topomax that this patient could have gotten without prior authorization?

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