OMG- I didn’t know about pre-authorized medications (drugs)
Pre-authorized or prior authorization refers to the list of medications insurance companies will automatically cover through the insured’s drug plan. Insurance companies argue that this practice ensures subscribers are not automatically given a more expensive product when a less expensive one is available
The last thing you want to do when someone you love has cancer is wait for your insurance company to okay or approve the drugs that have been prescribed. But this may very well happen. Not all drugs, especially newer ones, are automatically covered by insurance.
If the drug you’ve been prescribed is not pre-authorized, you will need to apply to have it approved. This process can be filled with unanticipated delays. I was made aware of our first delay when I phoned the insurance company to find out if the prescribed drug was automatically covered by the company. It was not. My next step would be to submit a request that it be covered. I was re-directed to the company’s website where I could download a form to start the process.
Now, remember it has taken months to diagnose my husband and come up with a treatment plan for his inoperable stage 2 brain tumour. Another hoop to jump through at this point in time was less than welcome.
Once downloaded and printed the patient needs to fill out their section of the form and the “prescribing” doctor needs to fill in the doctor’s portion. After both parts have been filled out the request to have the prescribed drugs approved can be submitted. In our case, the Drug Access Department at the Cancer Centre was responsible for submitting the request to the insurance company.
Delay#2/ The Maze
The instructions we were initially given (by my husband’s oncologist and nurse) were to simply contact our insurance company on how best to proceed. It sounded straightforward. In a way it was, that is except for the subtle delay provoking nuances that meant there was actually little that was straightforward.
We made the assumption that the oncologist we saw regularly was the one to fill out the form. We were incorrect. The prescribing doctor (the one who needed to fill out the form) was a different doctor and not our team’s leader or regular oncologist. Who knew? Who would have guessed? Not me.
If you make this error, you will have to wait until the error has been discovered. Then you will need to request that the form be sent on to the next (hopefully correct) doctor. This error can, of course, add days to the submission process- and these forms are processed in business days. Mondays to Fridays count: weekends and holidays do not. So be certain that the form ends up in the hands of the right doctor right at the beginning of this process.
If you are unsure as to who should sign the form as recommending the medication, ask for clarification from your team leader and/or your regular oncologist. Actually, just ask, even if you think you know the answer. It was a question I had no idea we needed to ask. I wish I had.
Delay #3 /The Detour
Sometimes the form will end-up in the drug access department before the doctor has signed off on it. This is not necessarily bad as the drug access personnel will advocate on your behalf (if asked) to get the doctor’s signature. Still, this little detour will further delay the approval process.
If time is of the essence (and it likely will be) you will want to contact the doctor’s secretary or nurse to make sure the doctor has been given the form and seen it. It is more than reasonable to ask when you can expect the form to be signed so that the process can be continued. Make a note of this date and follow-up.
Effectively advocating means it is also reasonable to call the drug access department to determine whether they have received the completed form. If they have not received it, there is no reason not to call back the doctor’s office to confirm that the form has indeed been filled out and enquire as to when it will be sent to the drug access department.
It is also reasonable if you are told that the form will not be signed for days for whatever reasons to ask again when you might expect that it will be signed and returned to the drug access department. These are the types of situations where the squeaky wheel gets the grease. When advocating on behalf of someone with a potentially terminal illness being direct (and always polite) trumps waiting patiently every time.
Once the form has been sent to the insurance company it is a good idea to follow up and ensure the form has been received by them. Feel free to ask if there are any problems with the form. Hopefully not, but if so, ask how best to fix the situation as soon as possible. Once you’ve determined the form has been received and all is well, it is a good idea to ask about when you might expect the form to be processed. Once you have this date, it is, of course, as before, a case of following up: rinse and repeat this process until the treatment has been approved, booked and begun.
Stay the course. Remember getting a drug onto the approved drug list is a process and not a dead end. Work it and keep moving forward.
Also work to remember to stay as well as possible, always.
Till next time, stay well, stay safe
Next Week: Things I didn’t know (Living with Cancer part 3)
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