Prior Authorizations 1

You Need Permission for This Medication Why?

Prior authorizations are one of my least favorite things to do.  Most other physicians will agree with me.  When I first started in medicine – back when dinosaurs roamed the earth – we didn’t have to do this.  Now, almost any time I write a prescription or order a test, it seems like someone is second guessing my clinical judgment.  Actually, they are.  And I, as a board certified physician, resent it.  It also takes an immense amount of time.  Patients and insurance companies do not feel the need to pay me or any other doctors for our time.

From personal experience, here are a few of what I consider to be wasteful or ridiculous prior authorizations.  OK, I will break my rule and use the “S” word.  Most of these are just plain STUPID.  You be the judge.  I’ll be anticipating your comments.

I have one insurance company that requires a prior authorization for birth control pills for EVERY patient under the age of 18.  They must NOT be prescribed for birth control.  Of course we in GYN use them for many other things, but isn’t it a nice side effect that your 16 year old isn’t getting pregnant?  I have to call once a year to authorize these.  Sometimes even if the woman is over 18.

I have another patient who is in her 30s.  She is autistic.  She is on Depo-provera to control her periods.  Since she has NEVER been sexually active, this is NOT for birth control.  The insurance company requires that I call them yearly.

Imitrex is a medication that is used for migraines.  It comes in pills, nasal spray and injections.  I have one patient who can ONLY get relief with the injections.  Her insurance company has this on the approved list, but I have to call them to authorize it and tell them that she HAS tried other medications.

I have another patient with fibromyalgia who is having difficulty adjusting the dose of a particular medication.  Every time I change the dose, I have to call Medicaid.  EVERY TIME.

My favorite story is a lovely patient I have who is in her 80s.  Sometime in the mid 1990s I put her on a particular estrogen vaginal treatment.  We tried several cheaper methods, but she had allergic reactions.  She has been on this medicine since that time.  About 5 years ago, her insurance decided they would no longer pay for the little estrogen tablet.  I spoke with the pharmacist.  I had to fax the entire chart.  For the last 15 years.  We finally got things approved.

Two years later, she switched pharmacy benefits plans again.  This time the pharmacy decided that we should try an estrogen patch.  We fought back and forth for FIVE DAYS.  I finally had to threaten the pharmacy benefits plan with “practicing medicine without a license”.  I also told them that her cardiologist and I were not willing to take the risk of giving her systemic estrogen.  If they wanted to assume the medico-legal risk of doing so, and do it in writing, I would be happy to let them. 

We got our approval.