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