Prior Authorization is a Pain
Last updated: June 2022
What is a prior authorization except a requirement designed to make a patient crazy? What is its purpose, if not to make a patient spend valuable minutes if not hours calling the pharmacy, calling the doctor, and messaging the doctor? It shouldn’t be so hard to get something that is already prescribed, and it is hard to understand the need for this back flip, making the doctor get approval from the insurance company before a prescription can be filled.
Let's talk about prior authorization
Healthcare.gov defines prior authorization as “approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.” The American Medical Association as a whole, and individual doctors in particular, are as unhappy with it as patients like me are. Physicians say it creates extra work and even deprives patients of necessary medication at crucial moments. According to the AMA, “Prior authorization is a health plan cost-control process that requires providers to qualify for payment by obtaining approval before performing a service. It is overused, costly, inefficient, opaque and responsible for patient care delays.”
Here's another expert perspective: writing for the Boston Globe’s STAT News, Brian Barnett, a psychiatrist at the Cleveland Clinic, said, “Years ago, insurers responsibly used prior authorization to steer providers away from brand-name medications to cheaper — and usually equally effective — generic alternatives. But over the last decade, prior authorization requirements have exploded. These days, they’re even required for generic medications for which no cheaper effective alternatives exist. Prior authorization requests are approved more than 80% of the time, raising serious concerns that insurers are reducing their costs at the expense of patients by relying on the ability of time-consuming prior authorization requirements to deter prescribing.”
I just needed my Vitamin D cream
Luckily it wasn’t a life-or-death situation when I found myself waiting for a “prior auth” for calcipotriene, a form of Vitamin D that is sold under the brand name Dovonex. But still, my dermatologist wanted me to use it on my hands, and it was nowhere in sight. I had run out. When I do have it, I mix it with topical 5-Fluorouracil (Efudex); the combination allows for a shorter treatment for actinic keratoses than using Efudex alone.
It's part of my routine
The tubes of Efudex seemed to be multiplying on my bathroom counter. I'm only kidding, but for some reason I had two, but the calcipotriene was held up waiting for approval. I could've paid extra for a compounding pharmacy to mix the two, but it’s cheaper and easy enough to mix a dab of each myself. A big follower of instructions, it only briefly occurred to me to go ahead with just the Efudex while I waited. I guess I kept thinking it would get approved more quickly than the week or so that it took.
I'm really confounded
I have no idea why a tube of generic Vitamin D would need prior approval. It can’t be that expensive. Hardly any other of my drugs need prior approval, not even gabapentin, which is primarily used to treat nerve pain and seizures. Yet as I write this, gabapentin is one of the most misused and abused drugs in the country.
I'm glad it wasn't more serious
It’s a good thing that I didn’t need to start the treatment on my hands RIGHT AWAY. But what if the delay let a little something fester and turn into a skin cancer? It is doubtful that it did, but still, red tape over a simple cream is a waste of time and energy.
Have you ever had issues with prior authorizations?
Do you sunscreen in the fall?