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Medical Forum / General / Pharmacy / April 2005prior auths
Curiously have "run into " an individual on another ng that insists that "some states" require providers to obtain prior auths on EVERY script written!! being a prescriber myself I simply could not convince him otherwise... what he describes is a provider seeing a patient,,deciding on a proper med,,,then getting on the phone/computer and contacting the carrier!!! yikes...we would be seeing 5 patients a day,,,not 28!! any opionon I can give this guy??? I suggested Medicaid or other state programs might have restricted formularies...but he insists it is with ALL companies...says I don't know what "other states" do.. help!!  SignatureHawki I seriously doubt that. I would like to see what states require this. Not only that but the insurance that the doctor charges for his/her services is not always the same that is used for Rx filling. There are some insurance plans that are very restrictive and I can think of a few people that require extreme amounts of resources in order to get the majority of their Rxs through the system. Not only does this make no sense at all, I have never heard of it. > Curiously have "run into " an individual on another ng that insists that > "some states" require providers to obtain prior auths on EVERY script [quoted text clipped - 14 lines] > > help!! >I seriously doubt that. I would like to see what states require this. Not >only that but the insurance that the doctor charges for his/her services is [quoted text clipped - 5 lines] > > Not only does this make no sense at all, I have never heard of it. he is beginning to change his story (surprise surprise!!) I believe he is referring to a pharmacist entering data on a script into "your" trusty computer...which then checks with the insurance companie's data base to make sure it is on formulary..make sure there is no notation in the patient's file about allergies,,etc...and that the same drug has not been dispensed in less than whatever their stated time frame is... he still insists that "many states" are now doing this...but NOW his explanation seems to totally leave the prescriber out of the loop..and be a transaction between pharmacy and carrier(which I believe you guys have been doing for years now!!) electronic transmission of scripts ...direct from prescriber to pharmacist...negating the having to carry a piece of paper called a prescription is surely in the future... but hey..even getting labs etc electronically in a "closed" system like Kaiser is rather haphazard at best...and KP still hand writes all their notes,,etc... don't ya just love when someone argues with you..and you know they are wrong!!! thanks for the reply >> Curiously have "run into " an individual on another ng that insists that >> "some states" require providers to obtain prior auths on EVERY script [quoted text clipped - 14 lines] >> >> help!! The electronic transmission of scripts has already happened where I am at in the Seattle/Everett area. A doctor uses his palm pilot or computer to generate an electronic script and then it is sent automatically via fax to us for filling. Of course this is only for the larger clinics. >>I seriously doubt that. I would like to see what states require this. >>Not only that but the insurance that the doctor charges for his/her [quoted text clipped - 50 lines] >>> >>> help!! > The electronic transmission of scripts has already happened where I am at > in the Seattle/Everett area. > > A doctor uses his palm pilot or computer to generate an electronic script > and then it is sent automatically via fax to us for filling. Of course > this is only for the larger clinics. and for the providers with palm pilots,,software etc etc just a ??.....is this to ONLY one pharmacy?? what if the patient doesn't want to use the one in the guy's palm pilot?? never doubted it was the future...doubted it was the law..and commonplace BTW...I live in a far bigger city than Seattle...not happening in my neighborhood.. just a FYI.. >>>I seriously doubt that. I would like to see what states require this. >>>Not only that but the insurance that the doctor charges for his/her [quoted text clipped - 50 lines] >>>> >>>> help!! >> The electronic transmission of scripts has already happened where I am at >> in the Seattle/Everett area. [quoted text clipped - 14 lines] > > just a FYI.. It can go to any pharmacy contracted with the service - basically any pharmacy with a fax machine or email. Most of these services will provide hardware and software to prescribers. Brad > just a ??.....is this to ONLY one pharmacy?? what if the patient doesn't > want to use the one in the guy's palm pilot?? I paid close attention to the nurse entering my Rx the other day. The software they use stores the pharmacies that I have had them sent to in the past and has a drop-down list of them. They have all the pharmacies in the area listed to pick from if I want it somewhere else. If I have the fax number for a pharmacy in another state, they can enter it and fax it there. What most patients don't understand is that the data needs to go through the Dr's computer/fax system, then the pharmacy's. Around here, it usually takes 15 to 20 minutes to arrive. It's not uncommon for the patient to get here before their prescription does. > BTW...I live in a far bigger city than Seattle...not happening in my > neighborhood.. We are in a much smaller place than Seattle and I wouldn't be surprised if half of our scripts come this way. Deb My son went to his doctor who gave him some samples of Nexium. He used the samples and told the doctor that they worked for him so his doctor faxed a prescription to his pharmacy. My son had to go to work and he asked me to go and pick up his Nexium because he didn't want to miss a dose that he would need to take the next day. His doctor had told him not to miss a dose. Well, I went to the pharmacy to pick up his Nexium and they told me that Nexium was not covered by his insurance. They called his doctor's office but the doctor had left town for two weeks and the backup doctor switched the prescription to Protonix. I picked up the Protonix and when my son found out about it he said his doctor had told him to take Nexium and he was not going to take Protonix. His copay was $35.00 and he lost that because the pharmacy would not take back the Protonix. He was able to get some more samples to make up for the cost of the protonix and the backup doctor was able to get the insurance company to approve the Nexium. It would have nice to have the prior authorization but what should he do in the future? Ora >Curiously have "run into " an individual on another ng that insists that >"some states" require providers to obtain prior auths on EVERY script [quoted text clipped - 14 lines] > >help!! > My son went to his doctor who gave him some samples of Nexium. He used > the [quoted text clipped - 45 lines] >> >>help!! you can call your insurance carrier and ask for a copy of their formulary...take it with you to doc's appt...and look up any new drug doc is suggesting... tho formularies get out of date rather quickly...and new drugs..like Nexium might not be approved at first... or...from the doc's office...you can have a staff member call your pharmacy and see if the new drug will "clear" their computer...then take your script there to be filled... if it is NOT covered you would know before leaving the office...then you have a choice of asking doc for a different med,,,or at least know that when you get to the pharmacy you will have to pay (more) our company charges a $35 copay for non formulary meds...which is way less than paying the full price... good luck >> My son went to his doctor who gave him some samples of Nexium. He used >> the [quoted text clipped - 56 lines] >and see if the new drug will "clear" their computer...then take your script >there to be filled... The doctor didn't want to even write a prescription, he just wanted his staff to fax the prescription at their own convenience. I waited in that pharmacy for over an hour because the doctor's office was not in the mood to fax the prescription until 6PM. >if it is NOT covered you would know before leaving the office...then you >have a choice of asking doc for a different med,,,or at least know that when [quoted text clipped - 4 lines] > >good luck That sounds like a good plan. However if he follows your instruction, a staff member would be calling the insurance company, not the doctor. So you would get to see your 28 patients instead of 5. What was that all about? Ora >>> My son went to his doctor who gave him some samples of Nexium. He used >>> the [quoted text clipped - 91 lines] > > Ora No...I didn't mean a staff member calling the insurance carrier...that indeed is a time waster... pharmacies CAN enter a "test" script for a med...to see if the drug is covered (at least mine will do that)...since the pharmacies are computer linked with insurance carriers..no one needs to sit on the phone trying to get approval or to see if it is covered.. actually...let's say you "hear" yourself of a wonderful new drug you think would be good for you (ahhh..direct to consumer advertising!!)....a friendly not too busy pharmacist could run a 'test" script thru their computer..with you standing there...and get a yea or nay on whether it is covered.. then of course you still need to see a provider to get evaluated..script written...etc.. getting an auth for a drug not on formulary DOES require that the prescriber make a phone call to some clerk (??)....some providers WILL do this for you...in fact..in many cases they HAVE to...if the med in question is one you really need...unfortunately...we all are VERY busy (those 28 patients!!)...so often you the patient don't get your drug approved..etc...in a timely manner personally I think the system sucks!!! takes up way too much of everyone's time...esp the patient,,,who also has a life,,a job..and probably NEEDS the med in question without all the hassle believe me...I understand these issues from a personal as well as professional point of view...I spent a huge portion of my time on the phone with our carrier...who delight in denying claims...terminating us "by mistake"...etc etc....I finally stamped my feet loud enough that I have my own personal "advocate"...a gal in a huge company who has gotten MORE issues resolved in a timely manner...funny thing....she and I have talked so much on the phone and via fax..that recently she told me she had my hubby's social security number memorized!!! she had entered it into her computer so many times....persistence pays off!! Ask until your son's insurance provider sends him a copy of its formulary. Doctors can't know the details of every drug coverage plan. My MS BC-BS provided a pocket size card of preferred drugs. If the doctor orders generic there is NO co-pay. If he orders a preferred (by BC-BS I suppose) then the co-pay is lower than if a none preferred drug is provided. It will PAY to know the details of your prescription drug coverage if you are concerned about paying the minimum out of pocket costs. > My son went to his doctor who gave him some samples of Nexium. He used the > samples and told the doctor that they worked for him so his doctor faxed a [quoted text clipped - 16 lines] > > Ora Ora wrote... [A story of a patient (her son) who was prescribed proton-pump inhibitor Nexium, but refused to try the ppi that his insurance company preferred. A torturous path ensued when the patient attempted to get the medicine that he wanted.] Sorry, I have no sympathy for the patient or you. By participating in his insurance plan, he agrees to the terms. Among them is the concept that only certain drugs will be used, and when a group of drugs exhibit similar properties, the patient will accept the more cost effective drug. Does your son also refuse generics? The patient may argue that his physician PRESCRIBED Nexium, not Protonix, but on the other hand a licensed, qualified physician reviewed the facts and felt Protonix was a reasonable and acceptable alternative. I guess your son knows more than physicians. The "prior authorization" protocols were NOT set up for the scenario you describe. I guess the patient made enough of a fuss that the health care system finally caved in to shut him up. I wish that would work when I go to the supermarket, or McDonalds. The story once again corroborates one of my 47 ineluctable truths of life: Everyone believes they deserve the best health care money can provide, but someone else should foot the bill. >From: Petepenguin@webtv.net (P T) >Subject: Re: prior auths >Date: Fri, 29 Apr 2005 10:10:57 -0500 >Ora wrote... >[A story of a patient (her son) who was prescribed proton-pump inhibitor >Nexium, but refused to try the ppi that his insurance company preferred. >A torturous path ensued when the patient attempted to get the medicine >that he wanted.] >Sorry, I have no sympathy for the patient or you. By participating in >his insurance plan, he agrees to the terms. Among them is the concept >that only certain drugs will be used, and when a group of drugs exhibit >similar properties, the patient will accept the more cost effective >drug. Does your son also refuse generics? >The patient may argue that his physician PRESCRIBED Nexium, not >Protonix, but on the other hand a licensed, qualified physician reviewed >the facts and felt Protonix was a reasonable and acceptable alternative. >I guess your son knows more than physicians. >The "prior authorization" protocols were NOT set up for the scenario you >describe. I guess the patient made enough of a fuss that the health care >system finally caved in to shut him up. I wish that would work when I go >to the supermarket, or McDonalds. >The story once again corroborates one of my 47 ineluctable truths of >life: >Everyone believes they deserve the best health care money can provide, >but someone else should foot the bill. WHAT??? You mean to tell me that you think the PATIENT should take a more "pro-active" role in their health care and actually PAY for medical services? Hehehehe....guess that means we don't get free automobiles, gasoline to burn in them, free maintainence for said auto, no free 16 bedroom/ 15 bath homes, no free groceries??? Sheesh...Pete, you make it sound like America is a semi-capitolistic society or something! Hehehe...C U L8R! Wiz <{;-) Wizard57M Glenn Gilbreath Jr. Registered Pharmacist http://members.surfbest.net/wizard57m@surfbest.net/index.htm -- DOS Internet, Close Windows and Keep the Internet Open! -- >Ora wrote... > [quoted text clipped - 5 lines] >Sorry, I have no sympathy for the patient or you. By participating in >his insurance plan, he agrees to the terms. No one asked you for sympathy. In your book probably the patient is always wrong. He is keeping you from the golf course. >By participating in >his insurance plan, he agrees to the terms. Not true. He participates because he has no choice. That is the only plan his employer offers. And don't tell me that his employer pays his premiums because they don't. > Among them is the concept >that only certain drugs will be used, and when a group of drugs exhibit [quoted text clipped - 5 lines] >the facts and felt Protonix was a reasonable and acceptable alternative. >I guess your son knows more than physicians. His doctor told him to use only Nexium because he had already tried Prilosec and it did not work very well. He was just making sure the system did not override his own doctor's decision. >The "prior authorization" protocols were NOT set up for the scenario you >describe. I guess the patient made enough of a fuss that the health care >system finally caved in to shut him up. They cooperated because that is their job. >I wish that would work when I go >to the supermarket, or McDonalds. When you go to the supermarket or McDonalds you have choices that we don't have with the health care industry. >The story once again corroborates one of my 47 ineluctable truths of >life: > >Everyone believes they deserve the best health care money can provide, >but someone else should foot the bill. If better health care is available for the money that the patient provides he should not settle for mediocre care. Ora Ora replied: >[This patient] participates because >he has no choice. That is the only >plan his employer offers. This is America, and there is always a choice. America is the land of the free, but that means, free to choose, not free beer. :-) (Now, who wants to buy me a beer?) What do you mean he has no choice to participate because that is all his employer offers? Then you go on to say that they don't pay his premiums? Well if they don't pay his premiums then he can go wherever he wants, since he is apparantly paying the premiums, and get better insurance coverage. I think you contradicted yourself. There are always choices. You son could get a different job with a better insurance company for example. Also the insurance company covered Protonix but you didn't say your son has already tried that. If Nexium indeed was the only thing that worked for him then I would whole heartedly agree that the insurance should cover it to a point. Absolutely. But I also believe in going through the steps of trying the less expensive therapies first and then getting the prior authorizations. This keeps health care costs lower for EVERYONE! The way you described your story is that you have a spoiled, whiny brat for a son that complains until he gets his way. >>Ora wrote... >> [quoted text clipped - 58 lines] > > Ora >What do you mean he has no choice to participate because that is all his >employer offers? Then you go on to say that they don't pay his premiums? >Well if they don't pay his premiums then he can go wherever he wants, since >he is apparantly paying the premiums, and get better insurance coverage. I >think you contradicted yourself. Come down from the rainbow. Private insurance costs considerably more than group insurance. >There are always choices. You son could get a different job with a better >insurance company for example. I see. You want him to quit his job over a prescription problem? It is easier to stand up for his rights. >Also the insurance company covered Protonix but you didn't say your son has >already tried that. He tried Prilosec which is the same as Protonix. His own doctor knew that but the backup doctor apparently did not and didn't bother to read his chart to find out. >If Nexium indeed was the only thing that worked for him then I would whole >heartedly agree that the insurance should cover it to a point. Absolutely. After trying the Prilosec he tried Nexium and it worked. So I guess you would have to agree. He had also tried numerous OTC meds. You don't need the rundown. >But I also believe in going through the steps of trying the less expensive >therapies first and then getting the prior authorizations. This keeps >health care costs lower for EVERYONE! Especially the patient. >The way you described your story is that you have a spoiled, whiny brat for >a son that complains until he gets his way. Whatever works. The squeaky wheel gets the grease. Apparently you only read part of the story. He has been on antiacids for years. Whatever works. The squeaky wheel gets the grease. Ora >>Also the insurance company covered Protonix but you didn't say your son has >>already tried that. > > He tried Prilosec which is the same as Protonix. His own doctor knew that but > the backup doctor apparently did not and didn't bother to read his chart to find > out. Actually Nexium and Prilosec are nearly the same thing. Protonix is a different drug, but in the same class. It really makes *more* sense to try Protonix if Prilosec didn't work. >>>Also the insurance company covered Protonix but you didn't say your son has >>>already tried that. >> >> He tried Prilosec which is the same as Protonix. His own doctor knew that but >> the backup doctor apparently did not and didn't bother to read his chart to find >> out. I stand corrected. They are not the same. Ora >Actually Nexium and Prilosec are nearly the same thing. Protonix is a >different drug, but in the same class. It really makes *more* sense to >try Protonix if Prilosec didn't work. First of all the pharmacy is the middle man and has no role in this problem. I realize that you did not say that it did but for other posters reading this it is good information. There are a couple of problems here. The patient had you pickup the medication and you were stuck making a decision as to whether or not to pick up the Protonix instead of the regular prescription. This happens frequently between spouses and causes many problems for the pharmacy. Know what you are picking up, how much it costs and what to do if something isn't right. Another problem is your son is not aware of what is a formulary item and what is not covered. This information is sometimes online with the insurance company. Other times you can call in advance and find out if it is covered instead of just dropping off your script and hoping it is covered. The final problem here is your ignorant and stubborn son. The doctor ok'd Protonix which the insurance company was willing to pay for and because your son wanted the purple pill he had to go through the prior authorization course. Things he could do in the future....verify insurance will pay for the medication before taking it to the pharmacy for filling. Have him pick up the medications incase there is a problem and the pharmacy has to ask him questions or have him make a decision on something. And last.....he doesn't need to insist that he has to have a particular drug when another, less expensive drug that does the same thing in the same class will work just fine. It is this kind of I am better than everyone else attitude that raises health care prices by causing the pharmacy, doctors and insurance companies to do more work just to get his Nexium approved when the Protonix was already approved. Of course it would be different if he had tried Protonix or Prilosec and it did not work. > My son went to his doctor who gave him some samples of Nexium. He used > the [quoted text clipped - 45 lines] >> >>help!! |
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