My wife has been on SS/Medicare disability for nearly 20 yrs.. over those years.. there is has been a lot of trail and errors in getting her overall therapy to a “good point”. Apparently Medicare Part D has decided that one of her GENERIC medications.. that she has been taking for over a DECADE now requires a PRIOR APPROVAL
My wife gets the first call from the Pharmacy that there is a PA involved and she calls the prescriber.. now the prescriber wants a office visit to fill out a prior authorization form.. She has Medicare and a supplement.. so it is not a matter of the cost to us.. but.. to me.. the cost to the system to go thru this PA BS for a therapy she has been on and stable for so long..
I first make a call to CVS/Caremark and got the “we will just send/fax a PA form to your doctor… NOPE.. let me talk to a supervisor… same response… NOPE let me talk to a supervisor.. finally got to a person who claimed to be a “clinical Pharmacist” and from his accent… ENGLISH was not is native/first language.
I identified myself as a Pharmacist and told this “clinical pharmacist” that I was not going to deal with interruption of my wife’s therapy and screwing with her quality of life.. I told him that I would appeal this issue all the way to the ALJ ( Administrative Judge Level) and what did he think their chances of prevailing with a Pharmacist doing the appeal.. up against .. a retired attorney/judge hearing the appeal… I know and he knows.. that >50% of people who get the ALJ level get their claims approved… I got “.. I have to fill out this paperwork… we are going to approve it.. but.. I need to fill out this paperwork…” After many back and forths… I get to the point that I am told ” I will call you back in a few minutes…”… which in few minutes.. I received a return phone call with a PA APPROVAL !
Filed under: General Problems
I just now got to read this , but yesterday I got up and called my husbands employer and they were not even aware of any such process, which just made me even more frustrated. But God is always right on time with the answer. The gentleman that was on the other end of the phone was also unaware of any such PA , because he also was on this same medication. I told him there was NO WAY I was going to wait 72 hours because I figured there would or could be some kind of withdrawal. So I politely told him , that if I must I would be going to the ER everyday until they got this PA finished up and he could let my husbands employer know until THEY got this taken care of I would be accruing hospital charges more than any PA cost. and since he also was on this medicine I asked did you get this same letter.. No he said. I said Wow that only tells me one thing and that could be possibly DISCRIMINATION . He immediately called and got a lady from PA on the line with CVS and I insisted on telling her my plans also of going to the ER and that she may want to share this with her Supervisor so they may also let our insurance provider , and my husbands employer know of the issue at hand . . she quickly told me if I would go to my Doctor and have them call this one phone number that CVS actually DID NOT have to wait on a PA fax.. Had it done within 20 minutes. 🙂
I am sorry that your wife has had to go through this rhetoric. Seems like with CVS Caremark they must love to torture those who have coverage with them . 2 Months ago they told me I must take my blood pressure medicine to a CVS Pharmacy or use a Mail Order Plan . Well we live in a very small town , and we don’t have a CVS within 30 miles. Next month , My Gyno prescribed 30 pills to be taken over a 3 month time .Well instead of paying $5.00 for all 30 pills I must pay 4.70 for 10 pills every month .. This month I go to pick up my Adderall that is in a generic form Amphetamine salt Combo , now I am being told that I must have a prior authorization . ( I have taken this medicine for the last 15 years now )When I look at the pharmacy denial form it says Maximum patient age of 18. and Plan Limits Exceeded. I have never had a problem getting this prescription filled up until now . I said that I cant believe that they would just let someone stop this prescription abruptly. The guy on the other end of the phone asks me if I couldn’t just pay for a few and they would try to work on it quickly as soon as they receive the PA. I told him what he was asking of me was against the law. if you don’t get the whole prescription filled then you lose the remainder. there is no buy a few here and there. deals with this kind of medicine. The pharmacist told me I was correct in telling him that also . Do they not have employees who can tell the correct information to patients. or do they even care. ? How very unprofessional. . Is there a law that protects consumers from just being denied coverage from their prescriptions when they have insurance that has paid for this without any issue up until now . ?
or Can CVS Caremark make up the rules as they go ?
IMO… disrupting a pt’s long term therapy is some where between practicing medicine without a license, and asking you to pay out of pocket is asking you to pay for something that they are already being paid to provide.. which – IMO – is fraud… At the very least they should have an emergency PA process to be able to approve the PA in 24-72 hr period. Then there is always the denial of medically necessary medications- which has been demonstrated if you have been on them for years.. and the personal health consequences to you are unknown if you experience some sort of withdrawal. I would suggest that you call them back and keep asking for a supervisor until you get someone to listen.. Do not be afraid of making it known that you are going to file a complaint with the state’s insurance commissioner.
Thanks for responding to her. Amphetamine withdrawal is nasty.
Oh snap, thanks! We just got a PA denial on one of my husbands meds, im not even sure why it was denied because his condition was one of the reasons listed as approved diagnoses. Planning to call them this week to find out why. Heck it took them THREE FREAKING MONTHS to decide to deny the med. This was one he had been on then couldnt get and now she wants to re start under another name/another salt.