Source: © Karolina Kaboompics | Pexels
This is part two of a pair of posts. Click here to see the previous post.
Last Monday morning, while I was getting my breakfast to take up to my office, I got a call from the insurance company that manages my medications: My appeal of its decision not to reauthorize my prescription of the antidepressant Pristiq was denied. I managed to keep from spilling my coffee and headed up to my office where I closed the door, and the tears spilled.
The American Academy of Family Physicians states that “Utilization management can complicate physicians’ lives by requiring them to submit precertification paperwork, deal with the fallout of denied services, and participate in time-consuming appeals.”
What was going to happen to me? I called the insurance company immediately and asked why the appeal to the prior authorization had been denied. The representative said it was because I hadn’t had sufficient trials of duloxetine (Cymbalta) and venlafaxine (EffexorXR). I’d been on duloxetine; it was the medication that had stopped working prior to my fourth suicide attempt in 2014. I couldn’t specifically recall being on venlafaxine, but in my three-plus decades of cycling through many medication cocktails, I was almost sure I’d taken it.
Although I knew the representative wasn’t the person who made the decision and had no power in reversing the denial, I couldn’t help spilling my guts. “I’ve been stable on Pristiq for 10 years. I suffer from severe depression. I’ve tried to kill myself four times. I don’t think the insurance wants to pay for another hospitalization which is significantly more expensive than the medication.” And I started to cry again. And I hung up.
I emailed my psychiatrist Dr. Lev informing her about the content of my phone call. I told her, “I’m terrified right now.”
She emailed me back a couple of hours later:
After 90 minutes, I managed to get the right fax # to the appeals dept. I’ve sent all the clinical info and stated it is urgent. For now, you need to buy a few tablets until the request goes through. I actually wrote a script for the succinate formulation that as per their letter is approved (in addition to an addendum to the first request indicating failure/intolerance of their recommendation).
An article published by the American Medical Association and authored by Jack Resneck, a dermatologist and the group’s past president, states that such tasks represent “a huge diversion of time and effort and resources” for clinicians. “These are hours that we could be spending actually taking care of patients as opposed to fighting all these appeals.”
Apparently, in addition to determining that I had not sufficiently tried duloxetine and venlafaxine, another issue the insurance company had was the original prescription being written for fumarate, not succinate. According to a prior authorization protocol, “Desvenlafaxine fumarate extended-release tablets is not a generic equivalent of Pristiq (desvenlafaxine succinate extended release).”
After being on edge for the next couple of hours, I received a text from my pharmacy that a prescription was ready. A pharmacy’s text doesn’t state the name of the script. Holding my breath, I called and asked the pharmacy desk if the Pristiq had been approved and they said yes. Calmly I told them “thank you,” and then did a happy dance in my office.
I emailed Dr. Lev: “Approved. Thank you so much.”
I went straight from the train station to the pharmacy to pick up the Pristiq. I took a photo of the bottle and emailed it to Dr. Lev. I am so grateful to her for the uncompensated and urgent time she put in on my behalf, and I am incredibly relieved. But why do we even have to go through such an ordeal? Why would an insurance company deem it necessary? In the AMA article, Resneck explains that “prior authorization has been around for decades, but it’s really been in the last several years that physicians and patients have seen it massively expanded—even to cover generics.”
All I know is that the insurance companies appear not to understand how a single “no” has the potential to turn someone’s world on its end. It puts lives at risk, both emotionally and physically. I’m thankful my case turned out in my favor, but I’m sure there are many people whose denials stand, and that stinks.
