New Rx

Pre-Approval

On my planet, if there were such a thing as prior authorization requirements (which is highly doubtful – on my planet we would just let doctors practice medicine to the best of their judgement) – I digress – if … then the rheumy’s office would phone/fax the insurance company to notify them of the new med, and away we’d go.

Sav-Rx tells me that it can take them up to 72 hours to approve a biologic.  So why does my rheumy says it might take a week?

The doctor writes the prescription and the patient takes the Rx to the pharmacy – just like normal.  BUT when the pharmacist goes to fill some prescriptions, the insurance company says “gotta have pre-approval for that.”  The pharmacy then sends a fax to the doctor’s office, where they are expecting the fax.  The nurse will be sure to complete the required paperwork and put it on the doctor’s stack of papers to sign.  Those papers will be signed the following morning and sent on their merry way.

Does this seem a little convoluted to anyone else?  Why can’t (spell-check thinks this shouldn’t have an apostrophe!) the doctor’s staff fax directly to the insurer when the prescription is written?  Why does the pharmacy have to be in the middle of all this?

Anyhow, yesterday I delivered the Rx to the pharmacy – day one.  In theory the pharmacy faxed paperwork to the doctor yesterday.  This morning my rheumy will sign everything so that her nurse can return it to the pharmacy – day two.  At some point during the chaos at the pharmacy, those papers will magically be transmitted to the insurance company.  If they’re really busy, or if the fax isn’t sent until evening, the insurer might not see the info until tomorrow.  Not until they log receipt of the paperwork does Sav-Rx start their 72 hour clock.

On Planet WarmSocks, three days would be counted {Wed-Thurs-Fri}.  On Planet Earth, {WednesdayThursday, Friday could be day one, SaturdaySunday, Monday is day two, Tuesday is day three}.  Which means it could be Tuesday before the pharmacy receives approval, and Wednesday before my prescription is ready to be picked up.

Samples

My rheumatologist gives the initial dose in her office (as a sample), and that would have occurred yesterday had I not been a little past due on one of my vaccines.  I’ll be back in town today for my tetanus shot (it’s been… shall we just say a few years more than ideal – oops).  I could have gone ahead with the Enbrel yesterday, but the tetanus shot is likely to be more effective alone so I’ll head back to town again on Monday for my first Enbrel injection.

Increased Risk of Infection

TNF-inhibitor warnings all say phone your doctor if…  Which doctor?! 
My PCP and rheumatologist both say, “either one” is fine.  Rheumy thought about it a little more and clarified:

  • routine cold/sniffles, no need to phone (but skip Enbrel shot that week)
  • fever/cough – call PCP (skip Enbrel)
  • hacking up phlegm – call rheumy and she’ll probably want a chest x-rays (skip Enbrel)
  • minor cut – no need to phone but wash it really well

Kids

I don’t recall telling the rheumatologist that my kids are homeschooled, but she must have discovered this somehow.  Yesterday, after our discussion of when/whom to call if I get sick, the doctor commented that “less exposure to illness” is one advantage to my kids not going to school.  True statement; most hser’s acknowledge this.  And my doctor got all flustered!  “I don’t mean to imply that they’re not getting an education… what I meant was…”  It’s okay.  Really.  My freshman is studying algebra and biology; my sophomore is studying geometry and chemistry (among other things).  I am confident that their education is appropriate and don’t get offended by well-intentioned remarks.  The kids aren’t exactly kept in a closet, but they don’t get exposed to all the germs they would inhale if they were in a classroom every day.

Normally I try not to take the kids with me, but the boys tagged along again yesterday and sat in the waiting room with a couple schoolbooks so that the day wasn’t a complete loss to them.  We have rules for when that occurs.  Things like be quiet, and don’t annoy the staff or patients, and I expect this assignment to be finished when I come out, and if the waiting room fills up, give your seat to a patient.  People always comment on how well-behaved the kids are, so I assume they really are behaving.  When they finish their assignments, they get to use their sudoku books.  This made people curious and my boys had to explain sudoku puzzles to everyone.  If the patients at that office are typical, I’m thinking doctors might like to add a few sudoku puzzle books w/ pencil to the magazine racks in the waiting area.

I received my fourth cortisone shot since July yesterday – pushing the envelope here.
Monday I
‘ll begin Enbrel.

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9 thoughts on “New Rx

  1. The way prescriptions are handled (or not!) can be a disgrace — or a comedy of errors — in the U.S. The CoE comes when getting a needed med takes weeks or even months longer than it needs to (and the patient suffers in the meantime). The true disgrace, though, is when the insurance company simply decides it won’t cover the prescribed med at all, which in most cases means the patient will not be able to take it. Which condemns the patient to more suffering or, perhaps, worse.

    It is this sort of situation that health care insurance reform should directly address. What meds a patient takes should be the decision of the prescribing doctor and the patient, not some anonymous insurance functionary.

    I hope the prescription is approved and filled in a reasonable amount of time, WarmSocks. And glad that your doc, at least, can offer you a sample dose. Sheesh.

  2. I think that’s so cool that you homeschool your kids! One day (if I ever have kids) I would like to homeschool them as well.

    By the way that is ridiculous about the convoluted prescription situation. I hope it comes in soon!

  3. I first found you over on RA Connect and have followed your blog here. I think the two of us were diagnosed at the same time and have followed a similar course of DMARDS (Plaquenil, then MTX). I started Humira about 2 months ago and had to go through the exact same pharmacy dance you describe. I was surprised that it went smoothly for me, and I hope it goes as well for you. I’ve had good luck with my biologic, it has made a huge difference. Take care and stay warm.

  4. Glad you finally got the RX for Enbrel. Yes, the paperwork does seem silly. In the meantime, the patient waits and the costs go up. And the govt. thinks they can run the system better?

    By the way, did you get TB tested also?

    Andrew

  5. @Wren: I agree that this sort of situation needs to be addressed. Medical treatment should be between doctor and patient, free from the medling of third parties. Not often that I’m looking forward to a shot, but this is one of those times.

    @Robin: Homeschooling is a lot of fun (and a lot of work). If International Rights of the Child is ratified, homeschooling might become illegal. The U.S. needs a parental rights amendment. Another political topic!

    @MRCO: Welcome. It’s good to hear that the approval process for a biologic can go smoothly. Thank you. Glad to hear it’s helping you.

    @Andrew: Yes, my TB test was last month, and I had chest x-rays in May. My rheumy is on staff at UW medical school, and seems to be right on top of current treatment recommendations.

  6. I have so many things to comment on about this post but since all my thoughts would fill a book (all good things!) I will just say good luck. And also that I found that the tetanus shot really hurts afterwards. Hopefully that isn’t the case for you, but I hope they warned you because no one told me and I had no idea what was going on when my entire arm muscle was sore.

    The insurance thing is frustrating. My son had a prescription that he needed, couldn’t wait for it. The doctor had no samples, so I had to pay it while we waited for the insurance to figure things out. They denied it. Even though the doctor said he needed it. So I paid. I had no idea what to do until finally a very kind nurse helped me find a drug that would work the same but they would cover. So I completely understand your frustrations with this.

    • Thank you. They did NOT warn me. I thought the pain in my arm was due to which person gave the shot. Maybe I can wait another 14 years for the next one :)

      One cool thing about medblogs is that I’ve learned there are frequently alternatives. If insurance won’t cover one drug, there might be a similar med that’s less expensive and will work just as well. Glad you were able to find someone who helped you with that!

  7. oooh, very exciting, Enbrel script. I hopeit passes through smoothly, good luck on Monday and very much wishing the kind of biologics success I’m having. xfx

  8. Pingback: Patient Assistance « ∞ itis

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