Prior Authorization How do you get insurance companies to approve medications

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Explain what a Prior Authorization is and How you get your insurance company to approve your medication. I explain what the process is and how it works. I also talk about how long it typically takes for insurance to approve medications. Discuss how you can get insurance to pay for the brand name medication and what to do if your insurance denies the medications.
more detailed information here pharmacisttips.com/PA

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@Zeldarw104 5 жыл бұрын

thanks, it really did help. I know what it's like to get a prior authorization, you're correct when you said it's a headache. Yikes!😔

@bigbub5219 Жыл бұрын

If a M D thinks a drug will help you. Why should you need to have Pryor approval? It's like a doctors degree means nothing to me.

@Shaneword99 5 жыл бұрын

dude!!! THANK YOU! Dear god im so confused about this whole prosses.my insurance hasn't covered a medication for over 2 years yet I know of other people at my work with the same insurance that get it covered.. im actually thinking about getting a lawyer.

@PharmacistTips 5 жыл бұрын

Thanks for watching, I hope you get your medicine covered.

@thhall459 3 жыл бұрын

Getting a lawyer won't help. The United States Federal Government and our elected legislators have given your insurer COMPLETE APPROVAL to NOT PAY for anything if they don't want to. The law is called ERISA, and it basically means that if your doctor prescribes the only medication that works in order to keep you from dying, they don't have to pay for it. You can die, and they are immune. Your health insurer doesn't care ONE TINY BIT about you, and they can brutally injure you with NO consequences. This should be criminal. It isn't. It is legal. BUT IT IS WRONG, and ONLY when ordinary people realize this and rise up and demand this injustice ends, it never will end.

@ledzepgirlnmful 6 жыл бұрын

Having switched insurance companies at the beginning of December '17, I have been having difficulty getting my script for Dronabinol 2.5 mg filled. My GI, and pharmacy have been working on this persistent problem. I am not an Aids pt, nor a cancer pt. But, but, I am living with a host of chronic pain, and digestive issues. I lost my stomach due to gastroparesis, and have narrowing of my esophagus, as well as a surgical sticture , due to a Nissan Wrap that had been placed over 14 years ago. I have a J PEG for most of my nutritional needs. I also suffer from almost constant N/V. I do have Phenergan, and Ondansetron 4mg ODT to have when not home. The Dronabinol helps not only with the nausea issue, but helps spark a bit of appetite in me. Since losing my stomach, I no longer feel hunger, like I used too. I don't understand why almost 2 months later, and I am still nowhere with BCBS. If I could pay full price for this every month, it wouldn't be an issue. I've been on this med for over 3 years, and BCBS has covered this in the past.... how many appeals do I have to file. I feel for my poor Doc's office, and my poor pharmacy as well.... it's not like they have any other patients to tend to.... So frustrating for all parties involved. I am lucky to have a great team of doctors and pharmacists (plus the pharmacy techs) taking care of me, trying to advocate the best they can. I also regularly contact my insurance. How do you deal with this type of issue × god only knows how many pts at any one time needing prior auth, and maintain your sense of sanity???? Please forgive me, for being long-winded, still can't fall asleep 0039 in the morning due to nausea and vomiting.

@PharmacistTips 6 жыл бұрын

This is a difficult situation, you and your health care providers are doing everything I could suggest to get the medication covered. I do hope your persistence pays off. It is frustrating when someone can't get a medication that is helping improve their life.

@ledzepgirlnmful 6 жыл бұрын

Pharmacist Tips Thank you so very much for responding. I'll keep hacking away!!

@thinslayer8026 5 жыл бұрын

I see this situation a lot. There are a few factors affecting this situation: 1. Prior authorizations expire. 2. Criteria change twice a year, at January 1st and July 1st. 3. The grandfathering process hiccups (specifically, the prior auth violates the Follow Logic and thus fails to transfer to a new plan). 4. The doctor's office rep may not have all the information. 5. The Prior Authorization rep/fax/system may not ask all the right questions to address all the essential criteria. ...and a number of other factors. Typically, when a patient calls to complain about this very issue ("It's been covered before; why is it suddenly denied?"), the most common cause of sudden coverage changes is a combination of subtle criteria changes and the quality of the information provided by the doctor's office. For example, at the start of 2018, most commercial insurance plans started implementing Morphine Equivalent Dose criteria (Medicare started that earlier in 2017). So patients ask me, "Why was my oxycodone denied? It was covered last year!" That's because the criteria were different last year. The situation is less common (or drastic) for non-opioids, but for office staff who aren't familiar with your chart notes, it can be challenging to accommodate these changes. PA Pharmacists often try to reference information from previous approvals, but as noted above, if the criteria changed, the information in those approvals may not be useful, so they may have to rely more on info from the doctor's office. It's a frustrating situation for everyone, both for the patients and for the prior auth reps who have to watch these disasters happen. My advice is to be patient, study any denial letters you get, and work closely with your doctor's office. In my experience, patients who do that stand the best chance of getting what they want.

@SL-ui9dd 6 жыл бұрын

this would help a healthplan customer service agent....

@selenazambrano6198 4 жыл бұрын

So if a medication gets denied for whatever reason why can’t there be like a plan B? What I mean by this is that if my medication for lidocaine patches got denied why can’t my insurance cover something similar ? Why send me a letter to guide me to appeal when they could just cover something that is on my formulary ?

@pgreene62 2 жыл бұрын

Very helpful

@PharmacistTips 2 жыл бұрын

Glad to hear that

@swat4hire Жыл бұрын

I have degenerative disease arthritis in my back in my back missing disks I've had 3 back surgeries and a broken fusion and have been labeled as A potential male practice risk so they will not treat me not even at a pain clinic where they said I was only gonna get worse and was not a suitable client My doctor said that's great that's what I needed to keep treating you No problems getting prior authorizations pushed through until my husband were tired and OPM got involved Opm decided I didn't need 3 pills A-day and they only authorize one pillar day on extended release medication that needs to be taken at least twice A-day but because of metabolism I take 3 A-day for 21 years. Before that I was on the roller coaster of the shortacting medications that lasted about 2 and a 1/2 hours before wearing off... Going from vikin to percocet and so on. Since my husband retired my prior authorization expired authorization expired in July and and we put it in again like years ago like usual and opium said no the quantities too high they only authorize 90 pills for a 30 day supply. Mind you I can't function or walk without this medication. If it wasn't for my doctor putting me on this stuff 21 Years ago I would not have been able to take care of my baby or four-year-old that we adopted from Foster care. Now after 21 years I have been waiting over a month or almost a month to get them to fix this. Now I'm being asked to write a personal request it's no request to appeal the case. Why do I have to get involved at all? We are paying hundreds of dollars a Month on insurance understanding that the government pays 72% of it... The medication is not expensive and is on the formularly list. The proper way to use this medicine is 2 or more per day not to exceed for pills A-day. I have been on the same dosage for 12 years. I do not lose my medicine. I do not call for replacements saying I lost it. I've been a great patient. What do I do can you please do a video with regards to how opium can change change the prescription plan of an insurance we've had for about 19 years.... And insurance before that for about 3 years 4 years.... Both are blue cross PPO and Etna PPO But it's not open season yet to choose a new plan it's a new plan and if it was the new plan would not go into place until January 15th and right now it is the beginning of October the 2nd week of October. How can they change the formulary?? How can they change my prescriptions like that? How can they make me jump through hoops like a pomeranian puppy at a dog show?? Especially when our insurance has not changed?!? Thank you and I'm a new subscriber

@ledzepgirlnmful 6 жыл бұрын

Medical Marijuana is available in my state, but, employer won't allow.

@daisy1339 6 жыл бұрын

I’m going to search your videos to see if you have one about prior authorization for maintenance medication, but I’ll still ask my question here if that’s alright. I suffer from a chronic cough condition and I have been taking a narcotic type syrup since 2010. Prior to January, this year, my pulmonary Dr was able to write a 3 month supply on the required handwritten script so I wouldn’t have to drive across town every 30 days. My new insurance will not allow this courtesy and will only authorize 60 days worth to be doled out every 30 days with a fresh handwritten script. I also must get a new authorization when the 60 day approval expires. The insurance rep told me there’s no appeal process for me to attempt to get a broader authorization time frame, does this sound legitimate? Also... Doesn’t my Dr have any input regarding this being an ongoing maintenance medication? Thank you for any insight!

@PharmacistTips 6 жыл бұрын

Sounds like a frustrating situation. Unfortunately, I don't think there is much more you can do. Even though you need this medication daily, most insurance companies consider it a short term medication. Some prescription drug plans have stopped covering cough medications all together, so at least yours will cover it 30 days at a time. I wish I had a better reply for you, best of luck

@thinslayer8026 5 жыл бұрын

I work in prescription drug Prior Authorizations, and I'm honestly surprised it's covered at all. The representative's answer is technically incorrect - the patient always has the right to appeal. The thing it, persuading the insurance to bend the rules and do things your way is a royal pain in the neck, so even though you can *technically* appeal, practically speaking, you might as well not have that right at all for all the good it does. Still, if you feel it's worth the time an effort, it can't hurt to try. You lose 100% of the shots you don't take, after all. And honestly, I've seen some pretty wacky approvals in my time. So my advice is to shoot for an appeal anyway.

@hardyhomestead 4 жыл бұрын

UHC and OptumRx refused to pay for my daughter's full prescription. She just had surgery and is in a lot of pain. No reason was given. Her Dr spent more than 20 min on the phone with UHC. I was also on the phone with them. I still don't know why the refused to pay more than 3 days on pain meds. We waited in the parking lot at the pharmacy with our daughter in pain for over an hour. We pay over $800 month in health insurance not inc. dental and vision. United Health Care has too much power. Health care is out of control.

@PharmacistTips 4 жыл бұрын

Insurance can be very frustrating!!

@quadare1 4 жыл бұрын

I am so nervous because I just started this job which I have to work to approve or disapprove of the authorization but I will be training for 3 months... I'm so nervous

@selenazambrano6198 4 жыл бұрын

Zack Pierce how it go ?

@quadare1 4 жыл бұрын

@@selenazambrano6198its actually not that bad but so far this is my first day

@thhall459 3 жыл бұрын

I feel for you. Realize that you are working for a company which is deliberately set up to hurt patients and physicians by denying care at every opportunity. And even when they are unsuccessful in their arduous efforts to deny an episode of needed care, your company still has the satisfaction of knowing that it has stolen forever-lost and priceless personal and professional life-time from every physician who is subjected to this abusive system when they have to go through this awful gauntlet. I encourage to get out of this line of work. Please don't be an enabler for this evil.

@a.a.6552 4 жыл бұрын

What if you have state insurance, and your doctor has made a request for 'Brand Name Only' under DAW, and your insurance denies your request, though the pharmacy refuses to dispense the medication if you pay cash ? The pharmacy I went to refused to allow me to pay out of pocket for a brand name variation of the medication my insurance company declined to pay for; why deny the patient the autonomy to choose what variation of the medication they'd like administered if they are opting to pay for it & they have their doctors approval? It seems like overreach by the insurance company to dictate what should be up to the discretion of the patient (especially if approved & supported by their physician).

@thhall459 3 жыл бұрын

Your pharmacist broke the law. Pharmacists don't have the right to deny you to have the brand name if you are willing to pay for brand name. Even if your prescription says "generic substitution permitted", you can STILL have the brand name if you wish to pay the price differential. Pharmacists refuse to understand what the word "permitted" means. As a physician, however, I will tell you that "brand name" is completely unnecessary 99.999% of the time, and you are wasting your money paying for "brand name" medications when FDA approved generics are available. But your pharmacist was doing what pharmacists do ... he/she was being a ruthless nonsensical bureaucrat like many of them are.

@clarannbjers3208 3 жыл бұрын

Ok so Ins Denies covering and the pharmacy refuses to fill for cash.... is the pharmacist allowed to do that?

@allsensesfiring 2 жыл бұрын

I'm going through this right now.🤔😳😳🤬🥴 The pharmacy can't dispense a prescription without Insurance authorization to fill. If your insurance ""won't cover it,"" or it's too soon to fill, then it won't even let the pharmacy run it through...is the only way I can describe that. If they won't cover it it's gonna cost you FULL PRICE. I had no insurance... I went into hospital with pneumonia. I applied for Medicaid, was approved. I was having my inhaler perscription filled at a Pharmacy prior (heavily discounted $20.) to Medicaid. With Insurance they switched it to the generic......fine. I had several adverse reaction symptoms to that including ""shortness of breath." which is why I was taking it (rescue inhaler) I told just to fill without Insurance and I'll pay cash. Pharmacist said it's $200 for that now that you have insurance!! As of now....I can't do anything without it, So I sit on the.couch. I can barely get around the house now. 😞

@rippin187 5 жыл бұрын

Why do gastro doctors offices claim 4-6 weeks in order to get a pre-auth for Hep C DAA drugs? What could possibly take this long?

@PharmacistTips 5 жыл бұрын

Your insurance must have several requirements prior to approving the medication. You could try contacting the insurance directly and ask them if there is a way to expedite the process.

@hyvarinenkerry 4 жыл бұрын

Does any of this seem criminal in the least?

@thhall459 3 жыл бұрын

Absolutely! I believe prior authorization is a brutal, mean-spirited, evil assault on patients and physicians. It is nonsense to talk about formularies. There should be ONLY ONE formulary, which is the United States Food and Drug Administration list of all approved medications. That means EVERYTHING that is legal should be "allowed". Prior authorization should be banned by law from the United States of America.

@hyvarinenkerry 3 жыл бұрын

@@thhall459 I caught both hospital and insurance company in fradulant billing. The catalist was prior authorization. Both hospital and insurance delayed payment for over a year and then processed me as out of network when I was in network. This wouid trigger my maximum out of pocket for out of network because I already paid my in network maximum. This was a price tag of $4000. From the outside people will simply claim clerical error. But being a victim of this twice before... I could see it was just common practice. Being prepared for this to happen, I kept a eye on things. I didn't have the time in my day to talk to both insurance and hospital. If anyone is reading, do as I did and contact your medical insurance broker. Render your EOBs to them and let them speak snake to the snakes. Keep in mind that the broker is really no friend of yours. It is important to them and their reputation when soliciting Buisness... And they are going to go about it in a expedient manner. Be careful because they are not your friend. Stay firm on your claim and make sure the resolution is the right one. I involved the broker to do the leg work and a snake will be able to move freely within a den of snakes. The next week and a half there were a few back and forth resolution offers. First was $800 charge and then it went to $0 after I suggested clear case of bad faith billing. Broker had a wide range of tap dance motions but ultimately knew the gig was up. While he talked to the insurance company about billing, it freed me up to talk directly to the hospital billing department that had it on recorded line and record that they were instructed to bill out of network. Now I know why the broker said there was no need to contact the hospital. Prior Authorization was the smoke screen in all billing attempts. It is nothing more than a delay and disqualifying tactaic. It is a profitable one and there is no enforcement. It I had died on the table... Insurance would have just denied.

@thhall459 3 жыл бұрын

@@hyvarinenkerry If you had died on the table, the insurance company would have actually been glad. They would still have all of your premium money, and they wouldn't have had to pay to safe your life. And the best news for them is they are legally immune from malpractice. They can kill people at will by denying care, with not only NO accountability, but guaranteed protection from the federal government. It is called ERISA and it protects them and hurts all of us. Patients need to wake up.

@bigbub5219 Жыл бұрын

Why buy insurance and they don't pay. Drugs would not be so hi if there was no insurance. All medical would not be so high if there was no insurance. My grandparents had no insurance in there day. And costs were reasonable think about it people