See Zenda/KFF Well being Information
A girl with a number of sclerosis needed to have the ability to stroll up the steps with out dropping her steadiness. Her physician prescribed drugs that helped, however then insurance coverage approval for the drug expired. “Why do I want a previous authorization for one thing that I’m already prior licensed to take? If my physician says that they need me on a medicine, why does my insurance coverage have one other say in that?”
— Jaclyn Mayo, Lunenburg, Massachusetts
Jaclyn Mayo has a number of sclerosis, an autoimmune illness that damages the nervous system and may mess with coordination and steadiness. To get steadier on her ft, Mayo had been attempting to shed extra pounds: A lighter physique places much less stress on the joints and results in higher flexibility.
After Mayo did not have a lot luck with weight loss plan and train, her doctor prescribed Zepbound, a GLP-1 weight problems treatment that suppresses urge for food.
“It was actually serving to me,” she mentioned. “I may go up and down stairs and never really feel like I used to be going to fall.”
As a cheerful bonus, the GLP-1 appeared to ease different MS signs for Mayo: She began sleeping via the night time, and the frequent numbness in her arms went away.
After being on Zepbound for seven months, she fell into an insurance coverage pitfall: prior authorization.
In August, her pharmacy would not refill her prescription, and it wasn’t clear why.
Are you struggling to navigate a well being system hurdle? Ship us your difficult query and we could assign a reporter to puzzle it out. Share your query right here.
She referred to as her pharmacist, then her physician’s workplace, the pharmacist once more, and eventually her insurance coverage firm. After talking with the insurance coverage firm’s pharmacy profit supervisor — a third-party firm that oversees prescription drug plans for insurers — Mayo found out that the advance approval her insurer had granted for the drug, often called prior authorization, had expired.
Insurers require prior authorizations for sure remedies or exams, particularly pricey ones. Once they do, your physician has to make the pre-authorization request to your insurance coverage firm, explaining why you want the therapy. Subsequent, the insurer decides if it agrees that the care is medically vital and if it should pay for it.
Mayo had been taking the drugs for lower than a 12 months and did not perceive why a brand new prior authorization was wanted so quickly. She mentioned she by no means acquired a letter or e-mail notifying her that the clock had run out on her first prior authorization. As somebody with a continual sickness, Mayo mentioned, she retains shut monitor of her medical paperwork. She seems like she did every little thing proper, which, she mentioned, made the scenario particularly infuriating.
See Zenda/KFF Well being Information
Her physician submitted the mandatory paperwork after which came upon the brand new approval would take seven to 10 enterprise days.
At this level, Mayo had been off her treatment for 2 weeks. Her sleep was getting worse, and the tingling numbness in her arms returned. So she requested that her prior authorization be expedited, solely to be taught that her physician, not Mayo, would wish to make the request for an pressing evaluate.
“That pink tape was utterly avoidable,” she mentioned. “And all that they wanted to do was talk clearly to me. After which I may have continued my treatment with out delays. However they did not.”
Why insurers need prior authorization
Medical doctors are sometimes annoyed by the prior authorization course of, however insurers argue it helps maintain prices down.
AHIP, the insurer commerce group previously often called America’s Well being Insurance coverage Plans, declined an interview request. However in an emailed assertion, it mentioned that prior authorizations are an vital safeguard that assist guarantee sufferers obtain secure, evidence-based care and retains protection reasonably priced.
In a 2024 letterthe American Medical Affiliation, which represents physicians, mentioned the way in which well being plans use prior authorizations is “opaque and overly advanced,” creating delays in care and higher administrative burden.
Sufferers are additionally annoyed. A current ballot discovered that 1 in 3 insured adults name prior authorizations a “main burden” to accessing well being care.
It is doubtless Mayo hit pre-authorization hurdles as a result of her doctor prescribed a GLP-1, an costly class of treatment. The extra pricey the therapy, the higher the scrutiny, mentioned Miranda Aide of the College of Pittsburgh, who research well being politics and administrative burdens inside the insurance coverage system.
Points with prior authorizations are widespread. Policymakers may standardize how insurance coverage corporations consider prior authorization requests to forestall extra Individuals from experiencing medical disruptions, Yaver mentioned.
“It is a solvable drawback, if we have now the need and the political circumstances are ripe. I do not suppose that they’re at this explicit second,” she mentioned.
Here is what to find out about getting prior authorization requests authorised in a well timed method.
1. Discover out when your prior authorization expires
Particular person insurance coverage corporations, and even the person plans inside these corporations, typically have completely different insurance policies for prior authorizations.
See Zenda/KFF Well being Information
“As you may think about, that turns into an absolute nightmare,” mentioned doctor David Aizuss, chair of the AMA’s board of trustees.
Whereas costly remedies usually tend to be focused for prior authorization evaluate, Aizuss mentioned it additionally occurs for low-cost generic medicine.
To determine how lengthy your prior authorization lasts, attain out to customer support at your insurance coverage firm or pharmacy profit supervisor, whichever handles your plan’s prior authorizations.
2. Do not procrastinate
Getting a previous authorization is not all the time fast, so construct in time for issues to go unsuitable.
It took Mayo practically three weeks to type out the prior authorization subject for her GLP-1 prescription. She made the preliminary refill request a few week earlier than her treatment was set to expire and ended up with out the drug for over two weeks.
3. Ask your physician to request an expedited evaluate
As you wait to your prior authorization to undergo, your physician won’t understand how a lot treatment you’ve gotten left, or that your well being could also be declining. You possibly can have your physician request an expedited evaluate. Although, as Mayo discovered, insurance coverage corporations and pharmacy profit managers will not all the time volunteer that as an possibility.
See Zenda/KFF Well being Information
When an expedited evaluate is suitable is up for interpretation, mentioned Kaye Pestainadirector of the Program on Affected person and Client Protections at KFF, a well being info nonprofit that features KFF Well being Information.
“Nobody is aware of the specifics of what pressing means,” she mentioned.
Federal rules require that pressing requests made by folks with employer-based plans be determined inside 72 hours. And, on Jan. 1, a federal rule took impact that creates the same requirement for all Medicare Benefit, Medicaid, and Kids’s Well being Insurance coverage Program plans. Nonetheless, this rule does not apply to drugs.
4. Take into account different therapy choices
When Mayo’s physician first advised that she attempt a GLP-1, approval for the precise treatment was taking a very long time. When it grew to become clear the request would most likely be denied, the physician canceled that preliminary request and put in a previous authorization request for a distinct model of GLP-1, Zepbound. It was authorised.
Ask your physician about therapy options. Well being plans have completely different formularies — lists of medicines which can be routinely authorised. It may be simpler to modify drugs than to struggle to get your well being plan to approve protection.
However remember that your insurance coverage firm would possibly change your well being plan’s drug formulary anytime and require you to get a brand new prior authorization.
5. Do not be afraid to enchantment
Submit an enchantment, even for those who’re apprehensive you may lose. Yaver mentioned that, based mostly on the analysis set to be revealed in her e-book, Protection Denied: How Well being Insurers Drive Inequality in americaindividuals who enchantment a previous authorization or claims denial win about half the time.
See Zenda/KFF Well being Information
First, determine the place to ship your enchantment. Normally, it is an insurance coverage firm, but when the therapy you want is treatment, it might be a PBM.
And make sure you embrace detailed information in your enchantment.
When you’re attempting to get approval for a selected treatment, Yaver mentioned, ship documentation displaying that you simply tried different drugs or remedies that did not work. This helps make your case and may pace up the method.
“I truly simply went via a previous authorization for my migraine drug,” Yaver mentioned. “It truly went via in a short time.”
Well being Care Helpline helps you navigate the well being system hurdles between you and excellent care. Ship us your difficult query and we could faucet a coverage sleuth to puzzle it out. Share your story. The crowdsourced undertaking is a joint manufacturing of NPR and KFF Well being Information.
KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is without doubt one of the core working packages at KFF.
