Prior Authorization for Meds

Insurance companies – those paying out money – understandably want patients to use the least expensive treatment possible.  If the money was coming out of my own pocket, I’d definitely want to try a $20 treatment before shelling out $100 (or the $80 drug instead of the $2,500 drug).

When a rheumatologist writes a prescription for a biologic medication, it’s expected that the insurance company won’t authorize the pharmacy to fill the script without first making sure that less expensive treatments have proven ineffective.  When I was first prescribed Enbrel, that prior-auth worried me.  I’d heard from others about insurance companies dragging their feet and taking an excessively long time while patients sat and watched their fingers and toes become permanently misshapen.  That worry was needless because everything went quite smoothly – it took two days.

Since then, I’ve changed pharmacies, insurers, and biologics, and discovered that things don’t always go that well.  It would be nice if step one was for the doctor’s office to fax a form to get the process started with the insurer.  Unfortunately, different insurers have different paperwork requirements, and it’s not realistic for a doctor to have on-hand the forms required by every insurer.  It would also be nice if insurers – once they received information – dealt with the information promptly, but that doesn’t always happen, either.

I’ve learned so much about the way the procedure works – or doesn’t.

The first step is to make sure that the doctor is looking at an accurate record of past treatments.  If you’ve ever changed doctors, there’s no guarantee (even if you provided all the information) that the information made it into your chart in the right format/location for your doctor to find that info when completing paperwork for the insurer.  My rheumatologist looks at her prescribing history to determine how long patients have been taking a specific drug, so she hadn’t taken into consideration the year+ that I’d taken meds prescribed by someone else.  It’s was a simple matter to add that information to the drug list so that it’s easily visible, but we had to first recognize it’s an issue.

The second step is to not dawdle in taking the script to a pharmacy.  The sooner your pharmacy gets the third-party reject, the sooner things get moving.  You can wait to contact the drug company for activation of a patient-assistance card until after leaving the prescription at the pharmacy.

Third, patients need to know how their insurer handles PA’s.  This, I’ve discovered, is key.  Some insurers want the pharmacy to contact the doctor, and some insurers want to do it themselves.  Find out who sends that the fax your doctor, and see if there’s anything you can do to hurry the process along.

One Friday I went straight from my doctor’s office to the pharmacy with my new prescription.  Ten days later I still hadn’t heard anything, so I phoned the insurance company to find out if there’s any way to speed the process up.  When the doctor prescribes a med to be taken every two weeks and provides a sample for the first dose, it’s ridiculous for the insurer to wait more than three weeks to process the paperwork to get the patient those subsequent doses.  That’s how long it took last time, and I was determined that this time would be different.

One would think that when the insurer tells the pharmacy that a PA is needed, the insurer would start working on it right away.  Not so.  My insurer could have – and should have – contacted my doctor promptly on Friday.  It would be incredibly easy to program the computer so that a pharmacy reject would trip a flag; the computer would then automatically (immediately) fax a form to the doctor’s office to begin the paperwork process for approval.  Instead, it’s a cumbersome process handled by snails, and my insurer didn’t even contact the doctor’s office until the following Wednesday.

The staff at my doctor’s office was expecting the insurance forms and returned them promptly; insurance logged receipt on Thursday – then did nothing.  When I phoned (four days later), they couldn’t even find the forms.  At least my call alerted someone to be looking, so this time it only took 17 days to get my approval.

I’m so glad I phoned, because I learned that patients can help the process along.  I now have the direct phone number of one of the people who handles PAs for my insurance.  I hope to not need another med change, but if I do, I can call him directly to expedite matters.

And if I ever get rid of this cold, I can take that second dose.


Emergency Prep & Drugs

Flood, earthquake, tornado, hurricane, terrorist attack… The list of possible disasters isn’t very long.  That doesn’t mean it isn’t important to prepare.

One small line in most emergency preparation lists suggests including an extra month of prescription meds in your emergency kit.  I wondered idly how one might go about doing that, but when nobody in my family was regularly taking prescriptions it wasn’t an issue.  Now it is pertinent.

The problem isn’t with believing it’s a good idea to be prepared.  The problem is the difficulty of obtaining the extra month’s worth of meds.

1.  Insurance will not pay for early fills.  If you want to get an extra month, the cost will be entirely out-of-pocket.  That might not be a problem for one or two less expensive medications, but it’s a big deal if the cash price of your monthly trip to the pharmacy is nearly $3,000.

2.  Even if you pay cash so that you can have an extra month on hand, there’s still a problem.  Prescriptions allow a specific number of refills.  If you pay cash to get that extra month early, you run out of available refills at the pharmacy a month early.

I’ve jerry-rigged a solution.  I do not wait 30 days to refill my meds.  For a while now, I’ve refill my prescriptions every 27 days.  The first month, that got me three extra pills.  The second month, I added three more for a total of six extra pills.  The third month, I was up to nine extras, and so on.  For some weird reason, every now and then the insurance company says it’s too soon to refill and I’ve had to wait the full thirty, but this usually works.  Doing it this way, within a year, you’ll have a managed to stockpile an extra month’s worth of most prescriptions.

This doesn’t work with methotrexate, Enbrel, or anything else that’s filled for four weeks instead of one month.  Having skipped my Enbrel when I was sick, I know that when dealing with the stress of a disaster, I don’t want to be without that particular prescription.  However, since I was already well into the process of trying to accumulate an extra month’s worth for my emergency kit when I got sick, I filled the prescription at the regular time anyhow (despite not being out).

It’s a good thing I did!

Add insurance change to the list of potential emergencies

They had the audacity to send out a letter last month with instructions that we should refill prescriptions before the end of the month (on our old insurance) because it would take a while to get everyone into the new insurer’s computer system, and it probably wouldn’t be possible for the pharmacy to verify coverage for a few days.  I could picture getting laughed out of the pharmacy if I tried that, so didn’t bother.

Next the insurer said they should have everyone processed by the 10th, but we could just pay cash and then submit a request for reimbursement.  I didn’t think that would be needed, since I last filled on the 10th and would just be stretching things out to the full thirty days.  Unfortunately, the 10th came and went without new insurance cards.  My dear husband, concerned that I wouldn’t be able to get my prescriptions, was duly impressed when I said that I supposed this counted as an emergency, and explained my strategy to him as I dug into my emergency supply.

It was nice to be prepared.  It wasn’t nice to need it, but it worked out.  I had to pay cash to get my mtx last week, because there’s no extra stash on that one.  The rest of my prescriptions, though, I’ve been able to take normally, without the stress of wondering when those insurance cards are going to show up.  The tiny effort needed to be prepared was well worth it.

Do you include a month’s worth of prescriptions in your emergency kit?

For more information on disaster preparedness:




There’s quite the discussion going on in the comments section of a post over on KevinMD.  A gross simplification of the issue is that a few pharmacists and pharmacy techs took offense to my suggestion that it’s unreasonable to charge $45 for a prescription if it’s possible to make a profit charging $5 for it.

What the pharmacists commenting on that post have said contradicts what my insurance company has told me, as well as what my pharmacist has told me when I’ve asked questions.  Summarizing the information provided by a few different commentors, then:

It turns out that things aren’t nearly as straightforward as they could be.  Insurance negotiates a contract with physicians, but at the pharmacy there isn’t quite as much negotiation power.  Pharmacies are in the position (even more than doctors) of having to take whatever amount insurers offer, or not accepting insurance at all (in which case patients will go elsewhere).

One point that multiple people have made is that it costs a pharmacy $7-12 to fill a bottle, plus the cost of the drug, regardless of which medication is prescribed.  In addition to paying for the medications that it sells, pharmacies must purchase prescription bottles and labels, pay labor costs to employees, and cover the costs of doing business such as facilities rental/mortgage, electricity, computers, refrigerators, etc.  Those stores that have $4 rxlists are losing $3-8 on every one of those $4 prescription they fill.  The stores make a profit on other items to cover the losses of their pharmacies (which are there simply as a convenience to get customers in the door).  That’s not something that standalone pharmacies are able to do.

As to pricing, usually companies buy goods at wholesale and sell them at retail.  One of the pharmacists who commented on the linked post says that the pharmacy world is different, and that what they call “average wholesale cost” is really suggested retail price, and that what the pharmacy pays for drugs is called ACQ (acquisition cost).  AWP is usually 33% above ACQ.

If I follow this, then AWC will never be less than the $7-12 it costs a pharmacy to fill a bottle (from here on in, I’ll use $10 as an average).  If pharmacies could charge AWC, then they’d be satisfied that they were getting a fair deal.

The problem arises because of insurance.  Insurers know that there’s a 33% markup between ACQ and AWP, and decided that’s too much.  Insurers knock 25-30% off AWP, leaving 3-8% markup, then tack on a dispensing fee.  The dispensing fee, however, doesn’t come close to covering the true costs of dispensing a drug, which means that the 3-8% markup is not profit, but goes to cover dispensing costs.

Insurers, according to the pharmacists, usually pay around $1.50 as a dispensing fee.  It might be as low as fifty cents or as much as two dollars, but it doesn’t approach the $10 that it costs a pharmacy to fill a prescription.

There’s a twist to that dispensing fee, too.  Some insurers will only pay a dispensing fee every thirty days.  People aren’t supposed to let their meds run completely out before getting refills, so I can see where that’s a huge problem.  If my insurer does this, the pharmacy only gets a ninety-nine cent dispensing fee every-other-month, because I don’t wait until I’m out to get my refills.

Another  pharmacist indicated that AWC only covers the drugs, and the 33% above ACQ doesn’t cover dispensing costs, in which case $10 needs to be added in order for the pharmacy to be making a reasonable profit.  If AWC=ACQ+33%, then what is the 33% for if it’s not supposed to cover labor, materials, and profit?  I think that’s where I’m still a little bit confused.

What it boils down to is that the insurer tells the pharmacy how much it will pay, and also tells the pharmacy how much to charge the patient (as a copay); neither of those numbers has anything to do with the “cash price.”  The quoted “cash price” means nothing if you have prescription coverage on your insurance plan.