Wednesday, October 12, 2011

Behind the Scenes

This is a non-formulary approval form.  Junk like this takes up a good part of my day.



Basically, this says that the medication I prescribed is not on the patient's insurance formulary.  A "formulary" is the list of medications that an insurance plan will cover.  All insurance companies have different formularies, and different plans within the same company have different formularies.  There is virtually no way for me to know what medications are covered on what plan.  To make things even better, formularies change all the time, depending on which drug company is in bed with which insurance company.  So, that medication that you've been taking for a year that works well?  Sorry, it might not be covered next week.

This form says that I prescribed a patient Prevacid.  His plan only wants to cover Nexium or Prilosec.  So, in order to get the patient the medication he wants and has done well on, I have to review the whole chart, fill out the form, and hope I come up with a reason that's good enough to get him his medication.

Remember, this work was just for one patient.  I usually have to fill out at least 10 of these forms a day.

Medications are not always approved.  And it is NOT MY FAULT!  Patients, I am on your side.  I want you  to have the medications I prescribe.  When your insurance company will not approve a medication, it is as aggravating to me as it is to you.  But, no, I can't just "write a letter to someone" or "call someone" to get your medication approved.  If your company doesn't cover it, thems the breaks.  You can pay cash or take an alternative medication.  When you chose an insurance plan, you agreed to all of the stipulations and restrictions.  That includes the formulary.  I do my best by trying to write for generic medications as much as possible, but some companies do not even have generics on formulary.

So, I'll keep on tackling the paperwork.  I hope this helps explain why the prescription that I called into the pharmacy is not sitting there waiting for you.  It's caught up in a mess of red tape.

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