In which I talk about prescription insurance …

Alright. I keep seeing this meme going around.

Before I start, I have a couple of points I need to cover. First, I am a certified pharmacy technician who has worked in retail and hospital pharmacy settings, and I am currently employed at a mail order pharmacy that services dialysis patients, where I am an insurance specialist with a focus on processing prior authorizations with insurance companies. So … I kinda have the knowledge base to comment on this sort of thing.

Second, and this is more of a disclaimer than anything else, but it is absolutely absurd that the health of the United States population has become so monetized to the point where a patient might not get the life-saving medication they need because their insurance doesn’t want to pay for it. There is so much that goes into this situation that I can’t remotely discuss it in one post, and I don’t have the expertise or understanding of all the different cogs to accurately traverse it all, so I’ll leave that to the plenty of other people who speak about those topics. Obligatory MEDICARE FOR ALL statement here, even if that meant I would have to find another avenue of employment.

Now that I have that out of the way, onto the meat: this meme is so simplistic that it borders on disingenuous. Health insurance companies, like any other industry, are reliant on being monetarily feasible, and pharmaceutical companies are, as well. Money is required for research, development, etc., so a certain level of conservative behaviors, particularly on the side of insurance companies, is expected. If a drug is very expensive for whatever reason – mind you, I’m speaking of the sitch in the United States here, not how I feel it should be or how it is in other countries – an insurance company is definitely going to question why they should pay such a large amount if there are less expensive alternatives available, and they’re going to make the doctor explain it to them.

Here’s a good example. A dialysis patient is prescribed Velphoro, a phosphorus binder that assists in the prevention of hypocalcemia (low levels of calcium in the blood). This is a relatively new drug, that combines effects of combinations of other drugs, and as such, is expensive. So the patient’s insurance company is going to require a prior authorization (I process so many of these specifically on a daily basis) because there are cheaper medications that have proven track records of providing similar benefits. They don’t have access to the patient’s medical records, which include results of tests, labs, trials, therapies, so they aren’t necessarily aware that this patient might have had an adverse reaction or less effective results from those other cheaper drugs. So the physician or the dialysis clinic has to provide it to them. In my experience, most of the time, if the doctor provides the required evidence in a timely manner, a prior authorization is approved, and the patient receives their Velphoro.

This isn’t true of all medications, of course, and I’ve seen prior authorizations denied for all sorts of reasons, sometimes because the insurance messes up and codes something incorrectly*, other times because the doctors didn’t provide a good enough reason for the company to fork over nearly five grand**, and still more for what just seemed arbitrary justifications or for even no cause at all.

We can also get into the fact that some insurance companies have contracts with certain drug manufacturers so they prefer them over others. Because I’m the most familiar with it, I’ll use Renvela as an example. Renvela is the name brand of the phosphorus binder sevelamer carbonate, and some states’ Medicaid programs will pay for Renvela instead of the generic. Why, I’m not entirely sure, but they require prior authorizations if you don’t want what’s on their formulary, the fancy word for what is basically a list of medications they will definitely subsidize. Most of the time, they’ll approve it if the patient has adverse reactions to the name brand or if the patient is proving stable using the generic, but you still have to go through the process. It’s a pain in the ass, but there is a reason behind it, despite what the above meme implies.

Now, it is sad and frustrating that we have to employ thousands of people to help patients navigate the complicated world of insurance. And like I said at the beginning of this in my disclaimer, the money aspect of health care is even more disheartening. But just know that there are those of us out here who are fighting the good fight and badgering insurance companies into getting you the medications you need.

* I spent an hour and forty-five minutes on the phone arguing with a company because they had incorrectly coded a patient’s year-long prior authorization for her 100% necessary seizure medication, which would have cost her thousands of dollars for a 30-day supply as opposed to the normal $15. I have never seen a more frantic person, and rightfully so.

** I’ve seen some responses that amounted to basically, “Because I SAID so.” Which … fine, you went to medical school, but you aren’t having to pay for this drug in any capacity, so …

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