The wacky world of prescription prior authorizations

It’s happened at last: the epitome of ridiculousness in the already pretty ridiculous world of drug prior authorizations. I wish I could say that I made this up.

I got a fax from a pharmacy requesting a prior authorization for a brand name drug called Protonix, one of a family of medications used to treat ulcers, acid reflux, and other forms of tummy ache. This happens. Because there are five different drugs in this class (not counting generics), there is no way I can keep straight which plans prefer which drug. Sadly, switching patients from one medication to another, even if it’s working just fine, purely because of which drug maker is in bed with which insurance plan, is an everyday event. No big deal.

Here’s the thing: the patient was already doing well on pantoprazole, which happens to be generic Protonix. What?

The fax from the pharmacy has more information: “The patient wants a prescription for brand name Protonix because she has a coupon that will allow her to pay only $4.00 for it.”

It just so happens that pantoprazole is already on the list of $4.00 generics!

But, says the pharmacy, that’s what the patient wants.

Problem. In order to get a prior authorization approved, I have to state that generic pantoprazole has failed to control the patient’s symptoms. I can’t do that because it’s not true.

So even if I tried to do the prior authorization, it would be denied.

Patient is out of luck.

Or is she?

I call her up and ask what’s going on. Turns out that because her co-pay for the generic is $20.00, she wants to use her $4.00 card for the brand name drug. Sounds logical from her end, right? Too bad I can’t do anything for her.

But wait, I can. Turns out there is a pharmacy chain that’s actually giving away free pantoprazole. Why would they do this? Because they’ve been able to get the stuff so cheaply, they know they’re going to make more money off her from other stuff she buys when she comes in to pick it up. They call it a loss leader in retail circles.

Patient is delighted to hear this. New prescription called in to different pharmacy. All’s right with the world, except the original drugstore is probably gnashing its teeth at having lost a script, when frankly all they had to do was write off $16 of her generic co-pay.

I keep saying, “Now I’ve seen everything,” but then I see more.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • ErnieG

    This is more than just wacky. These type of deals between insurances and pharmaceutical (volume discounting with poor cost transparency) lead to wasted and inefficient time for physicians and patients, time that is not considered in cost analyses. The market (i.e. the place where buyer and seller meet) is not between the pharmacy and patient, rather the insurance, pharmacy plan, and pharmaceutical companies, with physicians and patients as by products of these large marginal cost efficiencies. What is considered unethical by physicians (making decisions based on economic benefit) is on par for these large corporations. This will only get worse. Don’t look to Obamacare to help- they only sealed the deal.

  • NewMexicoRam

    Anymore, doctors are just limosine drivers.
    Yes, our hands are on the wheel, but the orders come from the rich guy in the back seat.

  • ninguem

    One time, I had a parting of the ways with a patient, diabetes/hypertension/dyslipidemia……..

    EVERY SINGLE VISIT he would ask to change prescriptions all over the place, to accommodate whatever prescription coupon he found.

    Any savings got gobbled up with testing to figure out where we stood with glycemic control, side-effects, etc., plus visits to figure out exactly what he was actually taking, so many prescription changes, wanted to make sure he wasn’t taking two ACE-inhibitors, that sort of thing, because of this month’s coupon compared to last month’s prescriptions.

    Finally said no, and he just went to another doctor.

    Of course, I had inherited him from another doctor he had exasperated.

    Medicare, of course.

    • heartdoc345

      Never fear, patients on the “exchanges” will be totally different from Medicare.

    • buzzkillerjsmith

      Look on the bright side, n. Your activities were likely quite useful to some drug company. Keep up the good work!

    • Suzi Q 38

      It is because these drugs are so expensive.
      Just ask him to lose weight instead.

      Yesterday I was in a hurry and forgot to eat breakfast.
      I only drank my fiber whatever.
      At lunch I ate a low sodium turkey sandwich loaded with veggies.
      At dinner I ate very little, as it was so hot,
      I ate a small bowl of fruit and a little potato casserole that my daughter made to go to a barbecue. Not the best things to eat, but not a full on meal.

      My fasting blood sugar this morning was 95.

      Not that it matters, but your former patient patient might have had obsessive compulsive behavior.

      This odd behavior that involves doing odd things repetitively for little good reasons is usually indicative of such.

      It sounds like a perfect scenario for a person with OCD:
      See the doctors to go get the coupons, get the prescription, then check with the pharmacist to see if the prescription works, then make sure to get the proper testing, check the internet to see if there are two ACE inhibitors. What are their interactions? When should he take his meds?
      On his end of it, he wants to do it. He has to do it, or he thinks something bad will happen.
      They are truly tormented.

      They will go from doctor to doctor, wearing each one down, because they have to do this.

      Until of course, one is astute enough to get to know them and nicely suggest that this may be OCD and he needs to try to stop.

      • Maura69

        If Social Security paid $1500. a month I would never have to worry…my dear I get $535.00 a month…and that’s a fact!

        • Suzi Q 38

          Wow

          • Maura69

            Try living on that and being single…fun but carefully doable…..there are absolutely no extras!

  • buzzkillerjsmith

    The solution here is obvious and I am stunned that it has not occurred to Dr. H. Find the person or persons who sent those faxes and beat the aforementioned person or persons severely about the head and shoulders with a large piece of wood.

    • Maura69

      Are you going to bail me out buzz???

  • Kristen Stuppy, MD

    So patient is happy, but how much time did you and your staff spend on this? Time = money. If she was charged for your time, would she be happy?

  • Trina Wood

    Why didn’t the patient just ask the pharmacy to charge her their $4 cash-pay generic price in the FIRST place, rather than running it through her insurance, requiring a $20 copay? Or better question – why didn’t the pharmacy offer her their fair price of $4 in the first place, without being asked? Ridiculous!

  • lissmth

    No more doctor-patient relationship. The only way out will be HSAs and high-deductible insurance, with price transparency and no networks involved.