Prior authorizations

Most health insurance companies contract with another company, called a “pharmacy benefits manager” or PBM, to restrict your access to your medications.

If you go to the pharmacy and are told “we need prior authorization from your doctor,” you should know that this statement is terribly misleading. What is going on is that your PBM is restricting your access to your medications, not your physician, and not your pharmacy.

To save money for your health insurance company, the PBM intentionally introduces considerable delay in the process of getting your medications. They do this through a variety of methods such as:

  • asking for long forms to be filled out, many of which are not available online,
  • insisting on personal conversations with me, often with 15+ minutes waits on hold,
  • turning off fax machines Friday afternoon and not turning them back on until Monday morning, and
  • taking two or three additional days to make a decision after all the information has been provided to them.

The good news is that most prescriptions will approved by your PBM. The bad news is that the more they can delay you getting your prescriptions, the more money they make.

It is probably as important these days to know your pharmacy benefits manager it is to know your health insurance company.

If you have complaints about delays in getting your prescription filled, I would suggest you call your insurance company and complain about their pharmacy benefits manager to them. The problem relates to a contract between your insurance company and another company where each benefits by blaming the other for any problems.

Please note that prior authorizations involving telephone calls outside your session fall under the category of “emergency paperwork,” and involve additional fees as these are issues that due to your insurance company, not to your clinical condition.

Although I am familiar with most of the major PBMs, if I am not familiar with yours, you will need to get the necessary forms from your PBM.

practice/prior_authorization.txt · Last modified: 2009/12/30 07:52 (external edit)
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