Prior Authorization…Getting Over the Hurdle!

Juan, a 34 year old male who has Type 1 diabetes and is on an insulin pump, calls me frustrated that he needs prior authorization (PA) for Humalog which did not require a PA last month. As it turns out, the formulary for his prescription medications changed in April. He is also frustrated because the last time he used another rapid acting insulin his blood sugars ran extremely high and very difficult to keep in range.

Frustration Ensues
In this world of ever changing drug formularies and health insurance challenges, keeping track of preferred medications and medications that require PAs is frustrating for everyone! That includes not only the patient, but also the pharmacist, medical office staff and prescriber. The process of prior authorization was initially implemented as cost savings tool. Yet it seems to have gone off rail at some point in the not so distant past.

So what transpires in the PA process?
In the PA process, the prescriber has to obtain approval from the health insurance company for payment coverage of the medication. The simplified overview of PA process is the following
• Prescriber sends prescription electronically to the pharmacy
• Prescription is processed by pharmacy staff and reviewed by the pharmacist and forwarded to the insurance company
• Notification of required PA is transmitted from insurance company to pharmacy
• Pharmacy communicates electronically to prescriber that PA is required
• Prescriber’s staff completes necessary documentation for PA
• Insurance company reviews and sends reply regarding PA

Minimizing the Challenge
So how can the frustration be minimized? Be informed about your formulary (a list of preferred drugs covered by your insurance plan) in terms of what medications are preferred as well as the cost of any deductibles and amount of copays. Compare the list of your current medications with those preferred by the formulary and note if PA is required. Keep in mind most formularies usually change at least once a year. Ask any formulary related questions to the human resources or benefits department at your employer. Formulary information may also be obtained at the website for your insurance plan.

Resolution
As it turns out, Juan’s provider and I worked together to get a PA submitted. It took about 72 hours for consent and now having the green light for the Humalog PA, I phoned the pharmacist to share the great news. Juan picked up his Humalog refill later that afternoon. A hurdle has been overcome for a person living with diabetes.

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