So what's the scam behind prescription prior authorization?

[Gravitycollapse]

I assume it's a scam since we're talking about insurance companies.

[djean111]

1. It means a clerk at the insurance company has the power to second guess your doctor.

Who may be prescribing the medication because the drug salesman was nice.
it's all a crap-shoot, really. The only sure thing is the profit.

[Gravitycollapse]

2. I just paid 95 dollars for two pills because I forgot I needed a prior auth for my meds.

Two fucking pills. And I'm nearly certain I won't recoup that if I ask my insurance.

[Bozvotros]

3. Depends on the context

Insurance companies have learned that if you make it harder or more time consuming for doctors to prescribe certain drugs they just won't do it as often. If your insurance clerks are hamstrung waiting for approvals they can't do other things. Most companies have set formularies of drugs they will cover at a greater percentage or without prior approval. They are usually generic. You can't get a new obscenely priced drug until you try the older or generic version first and it doesn't work. Even then it won't be covered like the ones in their standard formularies. With narcotics the insurance companies may only let the doctor write six or 12 scripts or dispense a certain number of pills before they require reauthorization. This ensures that the doctor is more likely to be aware of how many scripts she has written in case someone is making copies or adjusting the number dispensed.

[blue neen]

4. Big Pharma and Big Insurance.

I swear they work together on these schemes.

When the pharmacy puts your script into the computer, it should come up at that point whether that script needs prior auth. At that point, the pharmacy usually advises you to contact your doctor. If you have a doctor who is willing to call the insurance company, the prescription should go through.

Unless you needed the prescription asap, it's usually worth it to jump through Big Insurance's hoops.

[Fumesucker]

5. Are you criticizing the ACA?

Because your post sure comes across as whining about our bestest and mostest progressivist evah health care delivery system and *real* Democrats don't do that pony wishing shit.



More seriously...

[blue neen]

6. Prior Authorization.

This particular pain in our rearends has been around for decades, unfortunately.

[Fumesucker]

9. I know but it's galling to be forced into the for profit system and PA crap not be taken care of

The whole purpose of these hoops is to keep people from utilizing their health insurance, now health insurance has been made mandatory in order to "improve" health care there is no reasonable justification for these practices designed solely to make health care more difficult to access.

Your doctor knows what you need better than some third party who is not a doctor and has never even seen you.

[loose wheel]

7. Nothing, generally

It just means that the doctor sends a code to the insurance and insurance makes a quick call on the prescription. Realistically, it usually means a phone call takes place.

I need allergy medicine during the spring and fall, originally my OTC didn't have a generic brand. When I went to renew a few years ago, my physician called and asked if the generic was okay as my insurance wanted me to try that over the brand name. Same medicine, from the same line, only my copay was $10 instead of $30.

[TM99]

8. Scam or not, it is a pain in the ass

and can be deadly for those with other conditions needing specific types of medications that require prior authorization.

I can not use steroid based medications - period. It took 3 MD's almost 2 years to get my non-steroidal asthma and allergy medications approved. Two fucking years - during which I had to pay out of pocket or do without.

I was prescribed another medication and the MD gave me the one approved. I get to the pharmacist. He pulls up my records, says you can't take this with your history of seizures, and requests a different drug from the MD. It takes the MD 1 month to get the medication. I, again, had to pay out of pocket with no reimbursement once covered.

The first instance was a pain in the ass. The second could have been deadly for me. Insurance companies should have no say in the medical care I receive.

[TheKentuckian]

10. To control the purse strings mostly but in some cases to be responsible according to the law.

Making sure for certain controlled and classified substances are for FDR approved diagnosis (granting a doctor can prescribe off label).

So scammy but not necessarily a scam depending on why, when, and how. I also suspect that whatever it saves, it actually adds mu change more to overall system wide medical cost. People have to deal with all the paperwork and phone calls, it is a labor generator for sure.

[Control-Z]

11. It has been my experience

to have needed prior authorization for name brands or other meds not normally covered. My doctors have had to inform the insurance company that the medication prescribed was necessary and that an acceptable substitute could not be found (for any number of reasons).

I hope that helps.

[Recursion]

12. Same concept behind an HMO

Actually HMO's used to do it back in the 90s. It controlled costs and pissed off patients and doctors (and of course pharma).