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A lady with a number of sclerosis wished to have the ability to stroll up the steps at residence with out dropping her steadiness. Her physician prescribed drugs that helped, however then approval from her insurance coverage plan for the drug expired.
“Why do I need a prior authorization for something that I am already prior-authorized to take? If my doctor says that they want me on a medication, why does my insurance have another say in that?”
— Jaclyn Mayo, Lunenburg, Massachusetts
Jaclyn Mayo has a number of sclerosis, an autoimmune illness that damages the nervous system and may mess with coordination and steadiness. To get steadier on her ft, Mayo had been making an attempt to drop some weight: A lighter physique places much less stress on the joints and results in higher flexibility.
After Mayo didn’t have a lot luck with eating regimen and train, her doctor prescribed Zepbound, a GLP-1 weight reduction medicine that suppresses urge for food.
“It was really helping me,” she stated. “I could go up and down stairs and not feel like I was going to fall.”
As a cheerful bonus, the GLP-1 appeared to ease different MS signs for Mayo: She began sleeping by the night time, and the frequent numbness in her arms went away.
After being on Zepbound for seven months, she fell into an insurance coverage pitfall: prior authorization.
In August, her pharmacy wouldn’t refill her prescription, and it wasn’t clear why.
She referred to as her pharmacist, then her physician’s workplace, the pharmacist once more, then her insurance coverage firm. After talking with the insurance coverage firm’s pharmacy profit supervisor — a third-party firm that oversees prescription drug plans for insurers — Mayo discovered that the advance approval her insurer had granted for the drug, often called prior authorization, had expired.
Insurers require prior authorizations for sure therapies or exams, particularly pricey ones. When they do, your physician has to make the preauthorization request to your insurance coverage firm, explaining why you want the remedy. Next, the insurer decides if it agrees that the care is medically needed and if it can pay for it.
Mayo had been taking the load loss drugs for lower than a yr and didn’t perceive why a brand new prior authorization was wanted so quickly. She stated she by no means acquired a letter or e mail notifying her that the clock had run out on her first prior authorization. As somebody with a continual sickness, Mayo stated, she retains shut monitor of her medical paperwork. She looks like she did the whole lot proper, which, she stated, made the state of affairs particularly infuriating.
Her physician submitted the mandatory paperwork then came upon the brand new approval would take seven to 10 enterprise days.
At this level, Mayo had been off her medicine for 2 weeks. Her sleep was getting worse, and the tingling numbness in her arms returned. So she requested that her prior authorization be expedited, solely to study that her physician, not Mayo, would wish to make the request for an pressing overview.
“That red tape was completely avoidable,” she stated. “And all that they needed to do was communicate clearly to me. And then I could have continued my medication without delays. But they didn’t.”
Why Insurers Want Prior Authorization
Doctors are sometimes pissed off by the prior authorization course of, however insurers argue it helps hold prices down.
AHIP, the insurer commerce group previously often called America’s Health Insurance Plans, declined an interview request. But in an emailed assertion, it stated that prior authorizations are an vital safeguard that helps guarantee sufferers obtain protected, evidence-based care and retains protection reasonably priced.
In a 2024 letter, the American Medical Association, which represents physicians, stated the way in which well being plans use prior authorizations is “opaque and overly complex,” creating delays in care and higher administrative burden.
Patients are additionally pissed off. A recent poll discovered that 1 in 3 insured adults name prior authorizations a “major burden” to accessing well being care.
Mayo hit preauthorization hurdles doubtless as a result of her doctor prescribed a GLP-1, an expensive class of medication. The extra pricey the remedy, the higher the scrutiny, stated Miranda Yaver of the University of Pittsburgh, who research well being politics and administrative burdens throughout the insurance coverage system.
Issues with prior authorizations are frequent. Policymakers may standardize how insurance coverage corporations consider prior authorization requests to stop extra Americans from experiencing medical disruptions, Yaver stated.
“It’s a solvable problem, if we have the will and the political conditions are ripe. I don’t think that they are at this particular moment,” she stated.
Here’s what to learn about getting prior authorization requests authorized in a well timed method.
1. Find Out When Your Prior Authorization Expires
Individual insurance coverage corporations, and even the person plans inside these corporations, typically have completely different insurance policies for prior authorizations.
“As you can imagine, that becomes an absolute nightmare,” stated doctor David Aizuss, chair of the AMA’s board of trustees.
While costly therapies usually tend to be focused for prior authorization overview, Aizuss stated it additionally occurs for low-cost generic medication.
To work out how lengthy your prior authorization lasts, attain out to customer support at your insurance coverage firm or pharmacy profit supervisor, whichever handles your plan’s prior authorizations.
2. Don’t Procrastinate
Getting a previous authorization isn’t all the time fast, so construct in time for issues to go fallacious.
It took Mayo practically three weeks to kind out the prior authorization challenge for her GLP-1 prescription. She made the preliminary refill request a few week earlier than her medicine was set to expire and ended up with out the drug for over two weeks.
3. Ask Your Doctor To Request an Expedited Review
As you wait in your prior authorization to undergo, your physician may not understand how a lot medicine you might have left, or that your well being could also be declining. You can have your physician request an expedited overview. Though, as Mayo discovered, insurance coverage corporations and PBMs gained’t all the time volunteer that as an possibility.
When an expedited overview is acceptable is up for interpretation, stated Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, a well being data nonprofit that features KFF Health News.
“No one knows the specifics of what urgent means,” she stated.
Federal regulations require that pressing requests made by folks with employer-based plans be determined inside 72 hours. And, on Jan. 1, a federal rule took impact that creates an analogous requirement for all Medicare Advantage, Medicaid, and Children’s Health Insurance Program plans. However, this rule doesn’t apply to drugs.
4. Consider Other Treatment Options
When Mayo’s physician first recommended that she attempt a GLP-1, approval for the particular medicine was taking a very long time. When it turned clear the request would most likely be denied, the physician canceled that preliminary request and put in a previous authorization request for a distinct model of GLP-1, Zepbound. It was authorized.
Ask your physician about remedy options. Health plans have completely different formularies — lists of medicines which are routinely authorized. It is likely to be simpler to modify drugs than to battle to get your well being plan to approve protection.
But remember that your insurance coverage firm may change your well being plan’s drug formulary anytime and require you to get a brand new prior authorization.
5. Don’t Be Afraid To Appeal
Submit an enchantment, even in the event you’re apprehensive you’ll lose. Yaver stated that, based mostly on the analysis set to be printed in her book, Coverage Denied: How Health Insurers Drive Inequality within the United States, individuals who enchantment a previous authorization or claims denial win about half the time.
First work out the place to ship your enchantment. Usually, it’s an insurance coverage firm, but when the remedy you want is medicine, it could be a PBM.
Include detailed data in your enchantment.
If you’re making an attempt to get approval for a selected medicine, Yaver stated, ship documentation displaying that you simply tried different drugs or therapies that didn’t work. This helps make your case and may pace up the method.
“I actually just went through a prior authorization for my migraine drug,” Yaver stated. “It actually went through very quickly.”
Health Care Helpline helps you navigate the well being system hurdles between you and excellent care. Send us your tough query and we might faucet a coverage sleuth to puzzle it out. Share your story. The crowdsourced venture is a joint manufacturing of NPR and KFF Health News.
