If it weren’t so tragic it would be funny: the ongoing prior authorization nightmare
My latest entry will discuss yet another set of incidents of egregious behavior on the part of an insurer. This time it is involves a series of cases handled by Future Scripts prior authorizations department as well as their mail order pharmacy. Future Scripts which has a pharmacy benefits management arrangement with Independence Blue Cross.
https://www.ibx.com/individuals/member_resources/pharmacy/
In one particular incident, Future Scripts http://Future Scripts received the patient’s mail order for generic Concerta, an ADHD medication, around October 1. Two weeks later the patient had yet to receive the mail order three month supply, though Future Scripts left a message on her home phone “apologizing” for the delay and then giving their toll free number to call with questions. To make matters worse, the mail order form explicitly stated that the shipment was to go to her father’s office because he would be there to receive it whereas if nobody were home when it came to the house, it would be sent back because it requires a signature given that it is a controlled substance. Of course, for the second order in a row, Future Scripts sent it to her home, either completely ignoring the shipping address or failing to read the form and using the default member address. Luckily for her, she still got it, albeit 2 weeks late, because the postal carrier failed to follow through with instructions to get a signature, and that was after Future Scripts apparently talked with her local post office to assure that would be the case. A call to a Future Scripts supervisor produced admission of the error in shipping as well as a promise to “get to the bottom of why that happened.” To her dismay, she opened the bottle and the pills were not the same as the last prescription. Indeed, they were not the specified authorized generic by Actavis, but rather one that had been downgraded by the FDA to a BX rating, which means it is no longer considered bioequivalent. She had gotten this once before prior to knowledge that the change in rating had taken place and its clinical effect did not last through her day and she had more side effects as well (anxiety, headache) compared to either the actual brand or the Actavis generic. For more about this, check http://www.fda.gov/Drugs/DrugSafety/ucm422568.htm
New prescriptions were then provided to her, one for the 30 day supply she needed to get at the pharmacy and another 90 day prescription. Future Scripts, after being demanded to to so, refunded the copay she paid for the wrong prescription. She went to fill the 30 day prescription and…..a NEW prior authorization was required for an override, given she had just received the previous prescription last week. Imagine that?! Future Scripts informed me that they could (or would) not authorize from their end it but instead would require that a new prior authorization request be sent for their review, which sometimes takes two separate attempts, as I have often found that my first request is completely ignored. Many times I send the request again, only to get back a puzzling response that there is already an authorization in place or the ubiquitous but nebulous request that “more information is needed” (which is usually just a repeat of everything I have already provided and nothing more than an answer to their request for more information). She still does not have that authorization as of this writing and therefore still is without the proper medication.
In another series of Future Scripts mishaps with a patient’s medication that evoked the old Keystone Cops (https://en.wikipedia.org/wiki/Keystone_Cops)
I had sent an authorization for an antidepressant, Fetzima, for a patient who was in need of this. It took several attempts, and multiple replies to the “more information needed” type of requests, to get it approved. Things were fine from that end but the medication did not work for her, so it was changed to another drug in its class, Pristiq. Each time I sent the prior authorization request that Future Scripts demanded, (the medication was refused at the pharmacy because Future Scripts was refusing coverage till the prior authorization was completed), I received the following response repeatedly:
The above drug does not require review for the member listed above because null Member may have the prescription filled with applicable cost-sharing.
Repeated attempts to get Future Scripts to clarify this were met with the same letter. This occurred toward the middle through the end of September and as of this writing at the end of October we still have no answer. Fortunately I have been able to supply her with samples while we are still trying to get the issue resolved.
Future Scripts has really been on a roll lately. There is yet one other example I would like to highlight for my readers. I recently evaluated a new patient and diagnosed her with bipolar disorder. Often, people with this illness suffer from chronic sleep problems and she was no exception. The generic form of the sleep drug Lunesta was prescribed because it was one that she had not yet tried; others tried had failed. Given the severity of her sleep problems dating back to childhood, I decided that the 3 mg dose – the maximum dose – would be the most clinically appropriate choice. In their infinite wisdom, Future Scripts, despite never evaluating my patient, determined that that was not the case and after sending again two requests they informed me that the 1 mg and 2 mg options would need to be tried and shown to fail before they would consider the 3 mg strength. I played the game, resubmitted a request, and got yet another denial – for 3 mg, AGAIN. I submitted the lower dose request again and got back this reply:
The above drug does not require review for the member listed above because generic Eszopiclone 1 mg and 2 mg do not require prior authorization; the patient must receive a 30 day trial and have therapeutic failure to one of the two aforementioned strengths of Eszopiclone to receive approval for Lunesta/Eszopiclone 3 mg. Member may have prescription filled with the applicable cost-sharing.
What was not clear then was why the lower dose was still being denied at the pharmacy.
Clearly, something is terribly wrong with the way insurance companies can interfere in patient care. Perhaps there is some reason to take heart, though, based on a recent decision rendered in the US Court of Appeals, which ruled in favor of NYSPA (New York State Psychiatric Association) and the APA (American Psychiatric Association against UHC (United Healthcare), permitting a lawsuit to go forward against UHC for violating the federal parity law for mental health and dismissed all objections raised by UHC, which opens the doors for future claims against insurers. Maybe this is the first step to erode the ERISA shield insurers hide behind when making administrative decisions that interfere with or compromise clinical care. For more about that read here: http://www.nyspsych.org/index.php?option=com_content&view=article&id=304%3Aunited-healthcare-decision-8-20-15a&catid=20%3Asite-content
For more about the impact of ERISA on health care, read here:
http://www.huffingtonpost.com/wendell-potter/congress-needs-to-close-l_b_2271531.html
http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1099&context=yjhple
If you are a patient reading this, collaborate with your doctor to fight against denials of treatment, whether it is a prescription or some other aspect of your care. Remember, if you have a grievance you can also submit a complaint to your state’s insurance commission. http://www.naic.org/state_web_map.htm
Physicians and other health care providers, I know how time consuming this process typically is and I know the frustration it causes, but we are often both the front line and the last line of defense for our patients, many of whom don’t have the resources or energy to stand up to their insurance companies. It is incumbent upon us to be advocates, and if we can’t personally to designate someone on our staff to do so to meet patient needs.