Prescription prior authorizations

Hi, hopefully this isn’t old news for everyone and while it is not specific to our disease, I hope that you find this information useful. I thought that I would put it in our forum because we seem to have some degree of frustration from the vagaries of our disease (inability to know when and what will set you off) and the lack of understanding that we encounter- sometimes even from healthcare providers. Well, enough of an introduction! lol
This is an issue that will not affct most of us with our pain medicine because we are on Schedule II medications which require monthly visits to our doctor (this has just recently changed under some new DEA regulations which I will post after the other info). Anyway, in addition to the prescription itself, there is something else that the insurance companies require before they will pay for the prescription. This is called a prior authorization and is not needed for all medicines. Here is the information I got from a website:

Essentially, prior authorization is your prescription insurance company’s way of keeping costs down by making sure that your doctor has tried a less expensive therapy first, or that the medication your doctor prescribed is medically necessary.

If your prescription requires prior authorization (“prior auth” in pharmacy-speak), the pharmacy will contact your doctor to inform him or her that prior authorization is required. Your doctor’s office knows what to do and will contact your insurance company for you. The pharmacy will continue to attempt to bill your insurance company each day for the medication. The prior authorization process usually takes 3 to 5 business days, sometimes more and seldom less.

It’s important to remember that prior authorization may only last for a short period of time, and rarely lasts more than six months. After it expires, the process between your doctor and insurance company must be repeated.

While I haven’t found out the results yet since I just found out last night that the prior authorization for my Prevacid prescription had expired. It was quite a shock to expect a charge of $30 and instead see the register show $380!!! :o Anyway, the process (so far) seems fairly painless. I called my insurance company (Premera Blue Cross) and the representative explained what had happened. Actually the pharmacist thought the insurance company had discontinued coverage of Prevacid, but luckily that was incorrect, but that was why I called- to find out what the proton pump inhibitor d’jour was. After speaking with the rep and telling her the issue, she gave me a number to give to my healthcare provider for her to call in the prior authorization. While I was speaking to the rep, it sounded like a same-day type issue (depending on how quickly your doc responds to the request), but according to the site that I quoted above, it is more like a three to five business day process. I will let you know how this plays out, but it went fairly quickly and the insurnace rep was courteous and friendly.
Well, now for some much-needed good news for those of us who require Scedule II medicines to control our pain. The DEA has actually relaxed some of the prescribing rules for Schedule II drugs!!! Yes, you read that correctly. What they have done is to allow our physicians to write prescriptions for up to 90 days for Schedule II drugs! This new regulation went into affect December 19, 2007. Here is a quote from the proposed (at that time) regulation from the DEA’s own website:

Today, DEA is unveiling a proposed rule that will make it easier for patients with chronic pain or other chronic conditions, to avoid multiple trips to a physician. It will allow a physician to prescribe up to a 90-day supply of Schedule II controlled substances during a single office visit, where medically appropriate.

The Notice of Proposed Rulemaking is accompanied by a policy statement, “Dispensing Controlled Substances for the Treatment of Pain,” which provides information requested by medical professionals regarding DEA’s position on this important issue.

Also new today, DEA is launching a new page on its website (www.dea.gov) called “Cases Against Doctors.” Everyone will be able to see for themselves the criminal acts committed by those few physicians who are subject to prosecution or administrative action each year.

DEA’s guiding principle is to prevent the abuse and diversion of prescription controlled substances, which have become increasingly popular and deadly, without impacting the ability of patients with legitimate need to have full access to pain relief prescribed by their physician. DEA remains committed to the September 2001 Balanced Policy of promoting pain relief and preventing abuse of pain medications.

As I said, this regulation was officially adopted on December 19, 2007.
Well, after three days of the “fun” of a hardcore flare-up, I am now mainly just dealing with extreme GERD. Hopefully I will be able to get my Prevacid in a little while and this will help with the GERD. Wishing everyone a realtively pain-free weekend!

Hugs,
Warren

Warren,

Wow, Thanks for all that info! I am currently on Hydrocodone, I don’t think it is a sceduleII narcotic, but the effectiveness is wearing off and my PM dr said I may have to move up to sceduleII sometime soon.

I hope you get to feeling better soon and have a great weekend!

Take care
Cindy

Warren-
Thanks for the reminder about prior authorization. I have been blessed with two great PCPs that have never questioned my need for pain meds (the one that did, I got rid of), but I’ve never given them reason to - have just recently signed a paper concerning my use of them. At the time I thought it was funny because I have kept a record of virtually every pill since Sept. 27, 2007. I remember that day because that’s when I started taking Hydro on a regular basis. Unfortunately, a friend of a friend OD’d on pain meds and the death of Heath Leger was a reminder of why they should require prior auth., but it shouldn’t take so many days.

Last Nov. the Hydro every 6 hours - recommended limit - stopped working. Thanks to this site for the awareness, and a nurse suggesting it, I started taking Morphine Sulphate 30 for a while. Luckily the doctor didn’t give me a hard time. I’m not a pill popper, even for headaches, and when I went in for a stent replacement Dec. 6TH, I was only taking MS 15. Since then I have gone back to the Hydro, only as needed. They want to go back in and replace the stent again Mar. 12th - guess my body devours them - but I seem to feel so much better afterwards. Guess I’m luckier than most everyone on here, at least for now. Just wish I could sleep normally (it’s 3am MST).

A couple of months ago I made the mistake of saying Prilosec instead of Prevacid and had to wait on the insurance to change it. That was an unhappy month for my system so I can relate to your situation. If you have any suggestions for middle-of-the-night hot flashes, they would be welcome.

Thanks for taking the time to post because we all need updates and reminders and the info is always useful for new people on the site. If not for people like you, I wouldn’t know half of the things I do. Your input is appreciated. Best of luck to you and your body! Don’t you wish you had a dollar for every time you had to say “excuse me?” :slight_smile:

big hugs w/o pain-
Lawanna