A little game we like to play called Prior Authorization

Those of you out there who rarely get prescriptions filled, require inexpensive drugs, or don’t deal with insurance companies, probably don’t know what I’m talking about. Those of you who know the term “Prior Authorization” know EXACTLY the horror I speak of.

What happens is that health insurance companies place restrictions on expensive drugs, tests, or services, and require that doctors get permission to prescribe the said drug/test/service, and ensure that they in fact are medically necessary. Yes, you heard me correctly. Our PEDIATRIC ENDOCRINOLOGIST needs to get permission from someone at the INSURANCE COMPANY to prescribe a drug. Let that one sink in.

I find it humorous when I do an internet search for “prior authorization”, what pops up is a lot of cooperative sounding, '“we’re watching out for you and care about your health” bull. Health insurance businesses (yes, it’s a business) say things like, “This extra step helps both your doctor and the insurer feel comfortable that the medical item is needed and medically necessary for your care”

Are you SERIOUS?!

You’re probably saying to yourself right now, “No way Megan, this is asinine. Why would an insurance company question the medical expertise of a trained professional? OBVIOUSLY your kids and husband need to test their blood sugar before they dose their insulin. OBVIOUSLY they need insulin to survive. OBVIOUSLY this need isn’t going away.”

To which I say, “Hahahahahahah!”

Not only do we need to get the insurance company’s approval to receive our prescribed test strips for our glucometers, WE NEED TO GET A PRIOR AUTHORIZATION EVERY SIX MONTHS. FOR EACH PATIENT. And that’s just for test strips. We also need prior authorizations for Humalog, back up Lantus, and blood ketone test strips. We also need AN ADDITIONAL authorization, I believe it is called a “a prior authorization for additional prescription amount”, when the script is written for an amount larger than “normal”. Apparently the insurance company only thinks someone with diabetes should test their blood 3 times a day. This isn’t realistic. And yet, the patient and the doctor have to remind them of this EVERY 6 MONTHS, and say it’s ok that we need more test strips. Geesh!! There are 2 people on full-time salaries at the Barbara Davis Center who deal solely with Prior Authorization claim requests. It’s their job to send forms to insurance companies verifying medically necessary prescriptions, stating “yes, the doctor really meant it”. They do this 8 hours a day/40 hours a week.

So I play the game, because what other choice do we have? I call the insurance company and recite my script: “Yes, patient X, still has Type 1 Diabetes". “Yes, patient X, still needs to test their blood sugar 8-10 times throughout the day.” “Yes, patient X, has the type of diabetes that requires insulin therapy.” “Yes, I understand that patient X is on an insulin pump, however, we still need a backup supply of Lantus in the event their pump fails.” “Yes, I understand that Lantus is a tier 3 drug and will not be covered at the same rate as Humalog.”

When I’m really feeling snarky, I like to throw in some comments like “yes, they still have Type 1 diabetes….unless of course someone at United Health Care has discovered a cure?!” Or, “You know, my 9 year old daughter has been testing her blood sugar 8-10 times a day for the past 5 years because she just thinks it’s fun. You’re right though, maybe she doesn’t need to after all. We’re all probably just overreacting.”

If you don’t laugh, you cry.