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Pushing for prior approval
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It’s 6 p.m. on a Friday afternoon as a young mother enters her local pharmacy to have an antibiotic prescription filled for her sick toddler who has been spiking a fever throughout the day and complaining of an earache.

Anxious to get home and get her child started on the medicine, the mother waits for the prescription to be filled only to be told a few minutes later by the pharmacist that her insurance company requires a “prior approval” before they will pay for the medication and this will require the physician to call her insurance company.

As the pharmacist is unable to reach the physician and the mother is unable to pay for the medication out of pocket, mother and child end up going home empty handed.    

It’s 2 p.m. on a Tuesday afternoon as a recently diagnosed diabetic patient, who has just been dismissed from a three-day stay in the hospital, presents a prescription for a new diabetic medication that his doctor has prescribed.

Because the medication requires a “prior approval,” the physician is contacted and the process is started. Seven days and numerous phone calls later, the physician still has not been able to get the insurance company to grant the “prior approval” to pay for the medication.

Sound ridiculous? These type scenarios are exactly what pharmacists, physicians and other health care providers face on a daily basis in an ever-increasing insurance controlled health care environment.  

Last week, a senate study committee continued their meetings examining the “prior approval” process practiced by insurance companies in the state.

Inundated by calls from physicians, pharmacists and patients across the state who have grown frustrated by the “prior approval” process, the committee is considering forcing insurance companies to curtail the practice.      

Described as a way to control escalating drug costs, insurance companies require “prior approvals” on certain medications not included in their formularies.

When a physician writes a prescription for a medication not covered by the insurance company, the physician can either go through the process of obtaining the “prior approval,” change the prescription to a covered med or have the patient pay for the medication out of pocket. Since most of these medications are expensive, paying out of pocket is generally not an option for most people.

While many physicians and pharmacists consider this process to be nothing more than insurance companies practicing medicine, the need to control drug costs is understood.  And while the “prior approval” process has caused many physicians and pharmacies to add personnel to handle the extra paperwork resulting in higher costs, the need for the process is generally recognized.

However, at the urging of physicians, one of the issues the study committee is considering is making insurance companies share the liability caused by complications from prescriptions that were changed as a result of the “prior approval” process.  

Regardless of all the other issues, first and foremost in all physician and pharmacist’s concern is patient care — getting the medication to the patient as soon as possible.

Recognizing the need to have a system in place to control medication costs while at the same time experiencing the frustration of the “prior approval” process first hand as a pharmacist, I introduced HB 367 two years ago. This bill would require insurance companies to pay for up to a 10-day supply of each prescription requiring a “prior approval” once per year in order to allow time for the pharmacist or patient to contact the physician for approval of an alternate medication or to obtain “prior approval” from the insurance company.

While the legislation did not pass last year, I have every intention of introducing the legislation again next year. With the help of physicians, pharmacists and the insurance industry this common sense legislation will assure good patient care while helping to contain medication costs.