Alice in Pre-Cert Land
The wild and wacky world of drug pre-certification has become downright surreal of late.
Patient who has tried three of the four available nasal steroid sprays with inadequate response to each. I suggest trying the last one (which happens, in my personal perennially allergic opinion to be the most efficacious) and write the prescription. Not unexpectedly, I get a request for a prior authorization. I get the first sense of foreboding upon perusing the form: there is one -- and only one -- question:
Has the patient had an adverse reaction to [the preferred medications]?Well, no, but they didn't work. I write this extra information in around the single question on the sheet and fax it back. Surprise (not): the only acceptable criteria for coverage of the requested medication is an adverse reaction to the preferred ones.
What they're saying is that they will only cover medications that don't work for this patient.
That was the red pill. Ready for the blue one?
I see a patient who, I fear, has a peptic ulcer. I prescribe generic omeprazole 40 mg. (I am aware this is available over the counter, but in the quantities he needs it can get pricey. He pays for prescription coverage, so I figure I'll try writing it for him. And don't go telling me I should just write for Nexium. The response is the same for any PPI.) I receive a phone call from the pharmacy that the medication requires prior authorization, despite the fact that it's a generic. My staffer spends an outrageous amount of time on the phone being told she needs to call no fewer than three different 1-800 numbers. The final verdict:
The prescription will only be covered if the patient fails the OTC version.Okay, let me see if I've got this straight: they will pay for the prescription, but only if it doesn't work.
I'm sorry, but "WTF" just seems so inadequate. My mind hurts trying to twist its way around this nonsense. I need drugs. No, wait: they'll probably need pre-certification. I'll just have to settle for alcohol.