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Health Insurance (Expert Forum)
Prior Authorization on Rx
Answered by
Amir Mostafaie - health insurance, insurance
eHealthInsurance
Gold River - CA
This forum is for questions and support regarding health insurance issues such as Medicare, Medicaid, Long-term health insurance, COBRA, insurance portability.
Prior Authorization on Rx
by orangeblossoms, Oct 24, 2009 12:34PM
Hello,
Earlier this week I went to fill one of my prescriptions and was told by the pharmacy that my health insurance would not allow the refill as I had hit my 90 day dosage limit. I've been going through a lot of abdominal issues since July and have been given different medications to try over the course of the past 4 months. During this time I was given an Rx for Prilosec in both July and August, which reacted badly with my body so I stopped taking it. At the end of September, after having an endoscopy performed, I was Dx with severe Gastritis and given a new Rx for Protonix to be taken twice a day for 6 months which meant 60 pills/month. Being that Prilosec and Protonix are in the same drug class my insurance company has stated that I've hit my 90 tablet/90 day limit. The Protonix has finally helped with the pain and discomfort I've been having and now my insurance company won't cover it. Since this is the only drug that has helped me my doctor has sent a PA to the insurance company (Tufts) in the hopes that they will approve the Rx and allow me to fill it. I was told by my doctors office that this usually takes 2 days and then was told by the pharmacy that it takes a week.
My questions here are:
1. What's the general outcome of a PA? Are they usually declined or approved?
2. How long does a PA approval take?
3. What am I supposed to do if it's denied and I cannot take another medication or afford to pay the $300/month fee for the med?
I think that it's pretty ridiculous that I pay so much to have my insurance and yet when I need to use it, my coverage is declined. If I can't take this medication than I'm just going to be back where I was in July and I don't want to be back there. I was finally feeling almost like myself again.
Earlier this week I went to fill one of my prescriptions and was told by the pharmacy that my health insurance would not allow the refill as I had hit my 90 day dosage limit. I've been going through a lot of abdominal issues since July and have been given different medications to try over the course of the past 4 months. During this time I was given an Rx for Prilosec in both July and August, which reacted badly with my body so I stopped taking it. At the end of September, after having an endoscopy performed, I was Dx with severe Gastritis and given a new Rx for Protonix to be taken twice a day for 6 months which meant 60 pills/month. Being that Prilosec and Protonix are in the same drug class my insurance company has stated that I've hit my 90 tablet/90 day limit. The Protonix has finally helped with the pain and discomfort I've been having and now my insurance company won't cover it. Since this is the only drug that has helped me my doctor has sent a PA to the insurance company (Tufts) in the hopes that they will approve the Rx and allow me to fill it. I was told by my doctors office that this usually takes 2 days and then was told by the pharmacy that it takes a week.
My questions here are:
1. What's the general outcome of a PA? Are they usually declined or approved?
2. How long does a PA approval take?
3. What am I supposed to do if it's denied and I cannot take another medication or afford to pay the $300/month fee for the med?
I think that it's pretty ridiculous that I pay so much to have my insurance and yet when I need to use it, my coverage is declined. If I can't take this medication than I'm just going to be back where I was in July and I don't want to be back there. I was finally feeling almost like myself again.
Doctor's Answer
by Amir Mostafaie, Oct 26, 2009 03:49PM
, Oct 26, 2009 03:49PMTo: orangeblossoms
Dear orangeblossoms,
The process and outcome of pre-authorization is really case by case and depends on how good of a case is made by the requesting physician. We have seen the length of time anywhere from 2-10 business days depending on the urgency of the condition & treatment.
If by any chance your carrier does not approve your meds, I recommend that you check into obtaining your medication using forms & information on www.needymeds.org website. NeedyMeds is a non-profit with the mission of helping people who cannot afford medicine and I just checked & saw that specifically Protonix is listed as a drug that they can help you with. The information at NeedyMeds is available anonymously and free of charge. Let me know if you have any other questions.
Sincerely,
Amir Mostafaie
The process and outcome of pre-authorization is really case by case and depends on how good of a case is made by the requesting physician. We have seen the length of time anywhere from 2-10 business days depending on the urgency of the condition & treatment.
If by any chance your carrier does not approve your meds, I recommend that you check into obtaining your medication using forms & information on www.needymeds.org website. NeedyMeds is a non-profit with the mission of helping people who cannot afford medicine and I just checked & saw that specifically Protonix is listed as a drug that they can help you with. The information at NeedyMeds is available anonymously and free of charge. Let me know if you have any other questions.
Sincerely,
Amir Mostafaie
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Thank you for sharingthe good news; I am very happy that your PA was approved.
Happy Holidays,
Amir Mostafaie