Overrides and Prior Authorization

[Cyborg]

The last few days have been real interesting while trying to the script filled for my test strips. About a year ago I got an override to allow me to get 300 test strips a month. The procedure was pretty much painless and not an issue back then. Oh, how things have changed!

3 days ago I called in a refill for my strips. When I get to the pharmacy, they try to give me 200 strips, stating that my insurance will only cover that many. I explained, with no success, that I have an override (prior authorization) on file. Apparently the prior authorizations only last 1 year and my insurance company failed to send me the letter informing me that mine had expired. :(

So I called the insurance company, which tells me that they need a new script from my endo and they need the endo to fill out the required prior authorization paperwork. My endo faxed the script immediately, but failed to proceed with the prior authorization paperwork. Finally, after initiating the process myself and having my insurance company fax the paperwork to my endo's office, the nurse decides to get off her high horse and complete the process.

So, at this point I figure I'll call the pharmacy before I drive down there, just to be sure... Sure enough, insurance is still only allowing 200 strips a month. I then called the insurance company, again, and was told that the test strip manufacturer has a maximum daily use limit. WTF! :motz: Apparently, the manufacturer can dictate how many times a day you test. How rediculous... I then had to have my pharmacy call a special department at the insurance company, United Health Care, to request a Maximum Day Override. Unbelievable!

It was finally resolved yesterday and now I am able to get the 350 test strips a month my doctor ordered. :D I will probably have to go through this whole procedure again in a year, but at least I know what to expect...

[Ricros]

Wow never heard of that before. Now the med compainies can tell use how much we can get and use. If insurance was bad before.... Good luck next year.

[kel4han]

Cyborg, I went/go thru this sooooo many times with our UHC plan!! It seemed only a certain pharmacist or tech new what the **** they were doing, or put in the extra effort to "override" the system. I think our problem was that they were sending the 1st script they saw in thier system to the insurance, even though we had an increased RX on file. This happens almost everytime! And I have to say "look retard!!" scan thru there, and you will see the auth on file AND the 400 strips a month. They keep all past RX's on file and it throws our pharmacy off every time!:mad:

[JediSkipdogg]

I do agree that that is stupid. Especially on a non-prescription (you only need prescriptions for insurance to pay) item. I use to have that problem with my insulin when I did the walk in pharmacy. They said I needed this paper and that paper and it happened each refill time. Then I switched to mail order (as it was easier to use) and never once, not even the first order, did I have a problem. And I haven't even had to get a new prescription in 2 years. They just call/fax my doc and say it's time to renew.

I have heard (and not sure about the full truth on this) that there is a limit on Exubera. You can only order 1 box of each per month on 1 prescription. So if you need 2 boxes of 3 mg, then you need two prescriptions (cannot be on the same one at all) and must pay two prescription copays. That may have also changed, but I remember reading that somewhere.

[sweetcheeks]

my mom takes a pill and is required to get 2 scripts per month, 15 days on each script, the pharmacy dont even carry that pill, so they tell her she must call 2 days ahead of time in order to fill her script, now this is insane!

[notme]

Cyborg, I feel your pain. I go through this once a year with Express Scripts Pharmacy. Now I have a new plan that requires I pay for all of my meds in full until I reach an out of pocket of $2,500.00. So, I ordered my blood pressure meds in January. I ordered three weeks in advance so I wouldn't run out. They get the order on Thursday, process it on a Friday and then realize it is going to cost me $217.14. Ok....I know that, I ordered the stuff. But, because it is over $100.00 they have to call me and make sure I am aware of this before they send it out. No call. I don't know this rule so I assume my meds are on the way. A week and a half passes and no medication arrives. So finally, I call on a Wednesday and ask where my meds are. They tell me that it is on hold because they need authorization to process it. I give them authorization, but it has to go back and be re-processed now by the pharmacy. They process it on Thursday and it makes it back to the pharmacy on a Friday...uh oh the dreaded weekend. It makes it to the pharmacy on Monday but there is a 3-5 day wait to fill. I am down to about five days worth of medication at this point. And they wonder why I have high blood pressure?????? I ended up running out of medication the day before my Rx arrived in the mail.

Now the process started all over again with my test strips and my allergy eye drops. I live in California. We are in full bloom Spring (sorry to the folks that are still seeing snow). I have had two trips to the eye doctor for allergy related eye problems. I overnighted my Rx on the 14th of March. I still don't have it. I called on Thursday to see where it was and once again, they needed to wait for authorization because the bill was over $800.00. Hmmm I guess me telling them once that if I order it, I need it and I know what the bill is doesn't work. Today is the 24th, ten days later. It will be at least another week before I get to test and have some relief from eye problems.

I hate the whole **** medical field right now!!!!

I am so sorry I ranted on your thread. I feel better. LOL.

[tanyatype1]

Absolutely unbelievable you guys! Hate hearing stuff like this! (Now only if weeee ran the world......lol!):)

[Cyborg]

If I were king for a day! :secruity:

[sweetcheeks]

Cyborg, I feel your pain. I go through this once a year with Express Scripts Pharmacy. Now I have a new plan that requires I pay for all of my meds in full until I reach an out of pocket of $2,500.00. So, I ordered my blood pressure meds in January. I ordered three weeks in advance so I wouldn't run out. They get the order on Thursday, process it on a Friday and then realize it is going to cost me $217.14. Ok....I know that, I ordered the stuff. But, because it is over $100.00 they have to call me and make sure I am aware of this before they send it out. No call. I don't know this rule so I assume my meds are on the way. A week and a half passes and no medication arrives. So finally, I call on a Wednesday and ask where my meds are. They tell me that it is on hold because they need authorization to process it. I give them authorization, but it has to go back and be re-processed now by the pharmacy. They process it on Thursday and it makes it back to the pharmacy on a Friday...uh oh the dreaded weekend. It makes it to the pharmacy on Monday but there is a 3-5 day wait to fill. I am down to about five days worth of medication at this point. And they wonder why I have high blood pressure?????? I ended up running out of medication the day before my Rx arrived in the mail.

Now the process started all over again with my test strips and my allergy eye drops. I live in California. We are in full bloom Spring (sorry to the folks that are still seeing snow). I have had two trips to the eye doctor for allergy related eye problems. I overnighted my Rx on the 14th of March. I still don't have it. I called on Thursday to see where it was and once again, they needed to wait for authorization because the bill was over $800.00. Hmmm I guess me telling them once that if I order it, I need it and I know what the bill is doesn't work. Today is the 24th, ten days later. It will be at least another week before I get to test and have some relief from eye problems.

I hate the whole **** medical field right now!!!!

I am so sorry I ranted on your thread. I feel better. LOL.



OMG, do you have to send them in?? cant you just fill it at the regular pharmacy and pick it up the same day?

[HollyB]

I feel so lucky now. Our doc just writes the scrip "for one year" and I get as many as we need, no questions asked.

[JasonJayhawk]

I feel so lucky now. Our doc just writes the scrip "for one year" and I get as many as we need, no questions asked.

Each state in the USA has a different law regarding this on prescriptions. Not so easy to do since there is no socialized system in the USA to help pay for the meds.

I deal with the yearly test-strip limitation, too. It usually takes about 3 weeks for the mail-order pharmacy to work it out; luckily, the mail-order pharmacy is owned by the insurance company, but it's always a stressful few weeks waiting for the paperwork to be pushed through.

I'd be nice if they recognized that Type 1's need more. I guess this leaves me wondering, do the "typical" Type 1's only need 200 strips per month? What am I missing here!

Then again, Type 1's typically cost the insurance company more money than what they put in to the plan, so I consider myself lucky.

[Cyborg]

IMO, pumpers need to be testing even more often. As the minimum, I test:

1) when I wake (before I exercise),
2) after exercise (but before I leave for work),
3) before breakfast (usually at work),
4) 2 hours after breakfast,
5) before lunch,
6) 2 hours after lunch,
7) before I drive home from work,
8) before dinner,
9) 2 hours after dinner and
10) before bedtime.

I also test before treating a hypo and sometimes 4 hours after a meal (usually when I give a correction bolus 2 hours after a meal).

The simple fact that test strip manufacturers can dictate the maximum daily test allowance is absurd. Aren't they in it to make money? :hmmmm:

[JasonJayhawk]

The simple fact that test strip manufacturers can dictate the maximum daily test allowance is absurd. Aren't they in it to make money? :hmmmm:

[Conspiracy mode]
The insurance company might have an agreement with specific test strip manufacturers for lower prices. In order to get those lower prices, they might have certain requirements dictated (such as having a limit per day).
[/Conspiracy mode]

Maybe they just want to avoid a lawsuit from customers running out of blood due to an aggressive testing regime. :confused:

[JediSkipdogg]

I'd be nice if they recognized that Type 1's need more. I guess this leaves me wondering, do the "typical" Type 1's only need 200 strips per month? What am I missing here!

You are missing that there have been no large scale studies showing more testing has improved control. Heck, MM is currently in the largest study (called Star 3) in diabetes history since the one in the early 90s. And MM's study is only to show the benefits of CGMS usage and is expected to take 5 years. Nothing was ever done about showing the benefits of testing more. There does have to be a point where testing is excessive.

If you test every day every 30 minutes what good does that do you? Not much because you can't correct that often or the general person will be stacking boluses like crazy. With CGMS you are taught a little more about not correcting all the time and looking for trends to correct. You don't get that with basic fingersticking.

The other problem is type 1s and type 2s are still clumped in the same category. For 98% (my guess) of the cases, what good does that do? A type 2 on exercise, diet, or oral meds really has no need for more than say 3 a day. So a box of 100 should be plenty for a month. It's when you add insulin that you need more and unfortunately they don't see that.

There needs to be more diabetic studies with greater classification. Unfortunately, nobody wants to fund a multi-million or even billion dollar study these days when you really get nothing out of it (in terms of making more money unless the study is funding by Lifescan, Abbott, other meter companies.)

[Doug]

With UHC its all about the co pays ...

Before I got the override which took as described a bunch of work. They filled the prescription for 700 strips with 500 and just shortened the refill time ( numbers are examples )

So instead of having to wait 90 days I could refill at 75 days or whatever it turned out to be - that way they are NOT altering the Drs orders - BUT they are getting more $$

[Mich]

I have several meds that require prior authorization because my insurance (Sharp Health Care) says I could be using somthing cheaper in the same class. I pay more than $200 per month in co-pays alone.

It also takes a long time for them to determine that a new medication is actually in a new class. I am thinking of Zetia. It took their review committee a year to determine that Zetia was better than Colostid, which blocks vitamin absorbtion. Even with my endo telling them that I literally "froze up" from the use of statins, I had to pay the non formulary drug price. Eventually they added it to their formulary but charge the higher tier price. Even with all of that hoopla, they still require a prior auth each year and it's a guessing game as to when the time is up. Then I have to go through the same thing as you with EACH OF the meds that require prior auth-- about 10 phone calls to pharmacy and insurance company, pleading, a new prescription (go to the doctor, pay for parking, plead my case with the nurse or receptionist (I AM un-necessarily interupting their work!) and finally, take it in to the pharmacy. I can't do prior authorizations through my mail-in service.

In my view, the whole thing comes down to their trying not to pay for my meds and me being the squeaky wheel. I feel so bad for patients without my stamina!

I do feel lucky to have insurance at all though, don't get me wrong. I know I'm expensive but I'm worth it, as the LÓreal commercials say...

The key is to just relax, keep a log of phone conversations and order fill dates and be persistent. It's such a great way to spend your time :mad: Mich

[blacklightmike]

Logic problem: You are told to eat several smaller meals a day. Your insurance only allows for a finite number of tests per day. How do they expect you to accurately chart your progress if they won't support the actual amount of tests necessary to do so? Wouldn't it be in their best interests to have you healthier as a reult of frequent tests? Or would they prefer you less healthy and more of a burden on the system as a whole?

I've had no trouble getting my 90 days scrips filled, except for Byetta. 30 days only. This is the only weight-loss supplement I have, and it's working... less of me means less meds, less money they need to dole out. WTF?

And, while I'm on the subject, why don't pharmacies track your scrips and keep them in stock? I've run through all my local pharmacies for shoddy service over the last eight years, and I still can't get 300mcg. Synthroid scrips filled on time, ever... and I'm never compensated for the inconvenience of returning twice.

Get off my lawn! :mad: