‘In an effort to hold down costs, health insurance companies are changing the rules of medication coverage each year, and every year we need to respond to these changes. Toward that end, our office has hired an expert in this area, Jeff, to process these medication requests. We are doing everything within our power to fight this battle for you, but there are limits to our ability to achieve results.
Jeff has written a summary of his expert advice regarding this issue to educate you about this topic and to describe what we can and cannot do to assist you. Always remember, this is a contractual agreement between you and your insurance company, but we are here to help. Please read Jeff’s comments and do your best to assist us in helping you.’
Prescription Prior Authorization Update 2017
As many of you may already know, as an increasing number of both traditional and new medications have become very expensive, many insurance plans are refusing to cover them, requiring you to share more of the Rx cost or making you switch to a cheaper medication. These determinations can be hard to take if you are satisfied with your current choice and are told you must pay more or change.
Insurance companies change their preferred or “formulary” drug choices yearly and what they cover for you may also change. Prescriptions covered in one year, may not be covered in the next. As prices have risen, the number of formulary options for you has fallen. We expect this trend to continue.
As Dr. Lakin said, we offer prescription prior authorization assistance as a service to our patients. Many medical office do not offer this help and you are left to manage your medications on your own.
This year however, the process has grown extremely difficult and more time-consuming for many reasons beyond our control. To help make our efforts more streamlined and successful, we are asking all of our patients to be proactive in the process.
Here are our suggestions:
- Make sure your current prescription insurance plan is on file with us. Present your drug plan card to our front desk for scanning in case you need us to do an Rx pre-authorization (PA).
- Be informed. Review your insurance details annually. Confirm that your medications are still covered next year. If a plan makes changes, you may have to change as well to suit your needs.
- Be prepared to provide us with a list of your Rx insurance plans formulary if we need it.
- If the medication(s) you prefer is not covered, under Dr Lakin’s guidelines, perhaps consider switching to another similar drug so your insurance company will pay for it. We will always attempt to justify the necessity and to get your prescription medication approved, but if denied, we too must accept their final decision.
- If you do not want your plan’s non-formulary choice, and must pay cash for your Rx, shop other sources for a better price. Generally Costco, Walmart, Target and other discount pharmacies are more affordable. The GoodRx.com and Blink.com websites can also be helpful.
- Be patient. Prescription pre-authorizations can be a timely process, it may require many rounds of paper work to be submitted and considered before a final determination is reached.
- Lastly, participate in the PA process if necessary. Your Rx insurance plan has a contract with you and not with our office. After we have done our all, then become your own advocate. Call your plan if you are not satisfied. You are the client and they may ‘change’ if you ask and insist on it.
Another resource is Larry Spivack. He is a longstanding acquaintance and patient, and has an extensive history of working in the health insurance field. Now retired, he works with the Area Agency on Aging at www.aaaphx.org Call 602-264-2255.
We will continue to support your medical prescription needs. With our staff’s expertise and your involvement, we will try to get the best results for all concerned.