A woman dealing with multiple sclerosis sought a way to navigate stairs confidently. Initially, a prescribed medication worked wonders, but then the insurance approval lapsed. “Why must I go through prior authorization again for a medication I’m already taking? Shouldn’t my doctor’s recommendation suffice?” Jaclyn Mayo from Lunenburg, MA, questioned.
Mayo’s MS affects her coordination and balance, making her keen to drop some weight for stability. Losing some pounds not only lessens the pressure on her joints but also boosts her flexibility.
Despite her best efforts with diet and exercise, progress was slow, prompting her doctor to prescribe Zepbound, a GLP-1 obesity medication that curbs appetite.
“It worked wonders for me,” she recalled. “I could navigate the stairs without the constant fear of falling.”
Interestingly, GLP-1 seemed to improve other symptoms of her MS, such as restoring her sleep and alleviating numbness in her hands.
However, after seven months, Mayo ran into an insurance challenge regarding prior authorization.
In August, when her pharmacy didn’t refill her prescription, she was puzzled.
After contacting her pharmacist, her doctor’s office, and then the insurance company, she found out that the previous approval for her medication had expired.
Insurance companies often demand prior approval for treatments, especially pricey ones. Essentially, her doctor must provide a justification to the insurer explaining why a specific treatment is necessary, after which the insurance will decide if it will cover the expense.
Having taken the medication for less than a year, Mayo was baffled by the need for a new approval so soon. Add to that, she hadn’t received any notification about the expiration of her initial approval. As someone managing a chronic illness, she meticulously keeps track of her medical records, making the situation even more frustrating.
Her physician submitted the required paperwork, realizing later that new approval could take a week or more.
By this point, Mayo had been without her medication for two weeks, leading to worsened sleep and the return of tingling sensations in her hands. She asked for expedited prior approval, only to find out that her doctor must initiate that process.
“All it would have taken was clear communication, and I could have continued my medication without delay,” she said, highlighting the unnecessary bureaucracy.
Why is pre-approval required by insurers?
While physicians often find the prior authorization system frustrating, insurers assert it helps to manage costs.
AHIP, the insurance industry’s representative group, declined to comment in person but stated via email that prior authorization is crucial for ensuring patients get safe, cost-effective care.
According to a letter from the American Medical Association, which advocates for physicians, the prior authorization process is seen as convoluted and burdensome, often delaying treatments.
Patients share this annoyance; a recent poll indicated that a significant portion of insured adults view prior authorization as a major barrier to receiving care.
Mayo’s struggle to obtain GLP-1, which is recognized as a costly medication, likely contributed to her prior authorization challenge. The more expensive a treatment, the more scrutiny it often faces.
Experts note that prior authorization issues are widespread and suggest that standardizing the review process across insurance providers might alleviate some of the burdens on patients.
“We can fix this, but it requires political will and the right conditions,” one expert observed.
For those looking to get their prior approval done smoothly, here are some tips.
1. Know when your previous approval expires
Different insurance companies—and even different policies within the same company—may have varying rules about prior authorization.
2. Avoid procrastination
Since obtaining pre-approval can be time-consuming, it’s wise to start early to address any potential complications.
Mayo required nearly three weeks to sort out the issue with her GLP-1 medication. She’d tried to get her first refill about a week beforehand but ended up without it for more than two weeks.
3. Request a quick assessment from your doctor
While waiting, make your doctor aware of your medication supply and any worsening health issues. Asking for a rapid assessment may help, though insurance companies don’t always offer that option readily.
4. Explore alternative treatments
Originally, when Mayo’s doctors suggested GLP-1, it took considerable time to secure approval. When it became apparent that the initial request was unlikely to succeed, her physician modified the request to another GLP-1 medication, which was approved.
Consult your doctor for potential alternative treatments, as insurance plans frequently have preferred medications that can simplify the approval process.
5. Don’t hesitate to appeal
Even if you’re apprehensive about the outcome, filing an appeal can be worthwhile. Research suggests that nearly half of those who contest a denial succeed.
Provide detailed documentation in your appeal. If you’re seeking approval for a specific medication, showing evidence that you’ve tried alternatives that didn’t work can clarify your position and expedite the processing of your request.
