[CarrieH]

Some how I ended up being the medication prior-approval expert in our office. It was bad enough when I had to fight commercial insurance companies for Antihistamine, Cox 2, and PPI drugs... but now I have to fight the new Medicare drug plans for insulin?!

We have a patient that has multiple problems along with his diabetes that makes his sugars hard to control. He is already on Humilin and various oral meds. The doctor had to raise his Lantus to 200 units a day. I about 40 minutes just trying to get a phone # to call. I spent 3 more days trying to get a "prior-auth fax" form. I then spent the 4th day calling the prior-auth department about once every two hours (they had a long mid-afternoon "quality assurance" meeting according to the recording) until I finally got a person.

After that, I called the pharmacy who told me it wasn't authorized yet, so I had to spend another 20 minutes on the phone to explain to them that 200 units a day means 6 vials a month (because apparently they can't calculate that themselves).

A. Don't they know that it is dangerous and life-threatening to make a diabetic go without insulin if they need it? (and they wouldn't be on it if they didn't need it)

B. I thought there were laws that went into effect 4-5 years ago that required that an insurance company HAD to cover diabetes testing supplies and treatment.

I decided that they're not going to kill anyone on my watch... even if I have to get rude and nasty on the phone.

[grannynurse FNP student]

Originally Posted by CarrieH

Some how I ended up being the medication prior-approval expert in our office. It was bad enough when I had to fight commercial insurance companies for Antihistamine, Cox 2, and PPI drugs... but now I have to fight the new Medicare drug plans for insulin?!

We have a patient that has multiple problems along with his diabetes that makes his sugars hard to control. He is already on Humilin and various oral meds. The doctor had to raise his Lantus to 200 units a day. I about 40 minutes just trying to get a phone # to call. I spent 3 more days trying to get a "prior-auth fax" form. I then spent the 4th day calling the prior-auth department about once every two hours (they had a long mid-afternoon "quality assurance" meeting according to the recording) until I finally got a person.

After that, I called the pharmacy who told me it wasn't authorized yet, so I had to spend another 20 minutes on the phone to explain to them that 200 units a day means 6 vials a month (because apparently they can't calculate that themselves).

A. Don't they know that it is dangerous and life-threatening to make a diabetic go without insulin if they need it? (and they wouldn't be on it if they didn't need it)

B. I thought there were laws that went into effect 4-5 years ago that required that an insurance company HAD to cover diabetes testing supplies and treatment.

I decided that they're not going to kill anyone on my watch... even if I have to get rude and nasty on the phone.

It is not Medicare you are having the problem with, it is the provider chosen by the patient. Most Medicare Part D providers have put a limit on the number of pills or vials, that may be obtained each month. It is based on the average dosage, not on the patient's actual need or physician's order. I have to use five vials on insulin a month. I fully expect to run into a problem with my Part D provider because they normally authorize only three vials a month, despite my having a physician's order. I may just pay out of my own pocket to avoid the headache. As for endangering someone's life, they really are not concerned with that, only the numbers and their rules.

Grannynurse

[Judee Smudee]

Maybe you should contact your local representative in congress about this. They are the ones who write the legislation that cause situations like this. You won't do this patient very much good but if the problem is wide spread and Congress starts to hear about it from many sources it could start the wheels turning.

[Retired R.N.]

Originally Posted by Judee Smudee

Maybe you should contact your local representative in congress about this. They are the ones who write the legislation that cause situations like this. You won't do this patient very much good but if the problem is wide spread and Congress starts to hear about it from many sources it could start the wheels turning.

Don't stop with just contacting your congress people. Get as much publicity as you can for this denial of prescribed medications. Let the general public know the names of the insurance companies that are making life miserable for senior citizens. Letters to editors of newspapers and magazines may not all be published, but if they get enough questions from their subscribers who are asking them why they aren't publicizing the problem, we might get some action.

Also, some television channels have public service departments that are always eager to look into complaints from viewers.

Granted, you will run into some publications who will refuse to irritate their advertisers, but I think it's up to us to expose insurance companies who are only too willing to take our money but don't want to give us the medications that have been legally prescribed by our physicians.

Don't forget to mention this to every candidate for office who asks you for your vote in the next election!

[CarrieH]

Originally Posted by grannynurse FNP student

It is not Medicare you are having the problem with, it is the provider chosen by the patient. Most Medicare Part D providers have put a limit on the number of pills or vials, that may be obtained each month. It is based on the average dosage, not on the patient's actual need or physician's order. I have to use five vials on insulin a month. I fully expect to run into a problem with my Part D provider because they normally authorize only three vials a month, despite my having a physician's order. I may just pay out of my own pocket to avoid the headache. As for endangering someone's life, they really are not concerned with that, only the numbers and their rules.

Grannynurse

Medicare is the one who is allowing the prescription plans to put limits on certain medications. There should be no limit on insulin vials. That's like saying "You don't get the medicine you need because your diabetes is more severe than we think it should be." That's descrimination pure and simple.

You shouldn't have to avoid a headache to get something you truly need (and that they will give you anyway once you waste your time playing their games). They just hope you'll give up and save them a couple of bucks.