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dancesintherain

prior authorizations?

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anyone had to get a prior authorization for a drug before? I'd love to hear your experiences (getting it or getting it denied)

 

I have a drug I'd really like to have covered but the prior authorization lists four illnesses for the doctors to check the box (narcolepsy, etc.) and then lists "other illness" and leaves a blank space. The fact that they have other means they're at least open to it according to my pdoc...but it scares me still.

 

I know I won't know until it's turned in...but it helps to know what others have gone through down this path.

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Yeah, it always scares me too.  But I've never had any trouble with it...just a matter of getting the paperwork through all the right channels.  I hope it goes smooth!

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I've had to have 2 prior authorizations in the past for Effexor XR and then for Seroquel. The only time I had an issue with it was with the Effexor because my doctor perscibed me regular Effexor and wouldn't accept it. For some reason, they approved the xr version which is probably better for me anyway.

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I had to get prior auth for Abilify and Provigil.  The pharmacy took care of contacting my doctors and the doctors filled out whatever they needed to without a problem.  It just took a few extra days for me to get the scripts filled.  No big deal. 

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I've had to get prior authorizations for provigil, fanapt, and emsam. Fanapt was the most difficult to get through as my doctor had to demonstrate I'd trialed the other aaps. But really it was just paperwork and if your dr is for it and pushes usually they'll get it through, ime.

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I have never had any problems getting PAs.  Usually my pdoc (or whomever) faxes in the request and it is approved by the next day.

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I have only ever had trouble with getting Aciphex authorized, I guess it's really expensive? No problem with Seroquel or Abilify.

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It's been my experience that if the drug is on the formulary, you can get it.  It's the ones that aren't listed and you want covered that probably won't go through.

 

For me, I just take the script to the pharmacy.. they mention the PA, and then it gets worked out behind the scenes in a day or two - then I just go pick it up.  I think that for the most part, all the insurance wants is the doctor confirming that you need it.  They're not medical professionals, so they can't really claim that the doc is wrong.. but they require the statement.

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I don't know which part of the world you're in but here in the U.S. they take Axis I diagnoses like bipolar very, very seriously.  I have had to get prior authorizations for additional psych visits and additional tdocs visits.  Not once have they denied me.  As for the meds, pretty much whatever the pdoc prescribes is considered medically necessary and I don't they even CAN deny it.  The only issue I have had is that the insurance company wants me to try generic first before they will allow me name brand.

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<blockquote class='ipsBlockquote'data-author="Cetkat" data-cid="629070" data-time="1358962847"><p>

It's the ones that aren't listed and you want covered that probably won't go through.<br />

<br />

The ones I mentioned in my precious post are or were non-formulary for my plan and they were all covered eventually and my coverage affiliated pharmacy even orders them in for me despite the official thing being non-formulary, must go to outside pharmacy to obtain. Never hurts to try.

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I've been denied several until I had tried other medications that my insurance wanted me to try first, all of which-surprise!-were cheaper. But none of those were for psych meds. They were for allergy meds and, once, for an inhaler. Nice, right?

 

The worst psych med experience I've had was with Ambien. I can't take the generic. My pharmacy never shows any initiative in getting the pre-auths for me. I have to make sure my doc's office (and they are awesome) contacts the insurance company, and then I have to keep on the pharmacy to keep checking to see if the authorization has come yet.

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I have not been denied for any psych med, although often there are a great man hoops to jump through. I have been denied some biologic meds for RA/Lupus and more than a few chemo drugs.

 

With a good doc behind the choices and a bit of determination you, my friend, will succeed to get the meds you need.

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thanks everyone for all the experiences--it sounds like there's a good number out there that went well.

 

mine's been mentioned by a few...provigil. it had a great effect and I finally wasn't absolutely exhausted from the moment I woke up until I went to bed (early)...but my insurance company seems to think it's for sleep disorders only. god willing, my pdoc will get the PA through.

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I forgot one thing until now ... sometimes for a PA to get approved you need to have tried other meds first, which have all failed in helping you. 

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we've tried certain anti-depressants known to be activating (the wellbutrin was to hopefully help with that), certain sleep drugs to see if I just needed better sleep, and some AAPs that are known to be more activating (geodon, abilify). but I understand that sometimes they have their own list.

 

I just hope it goes through...

 

edited to add - I have ot admit that it still freaks me out a little. that plus the fear that once we get all this through, it'll poop out on me at some point after being so great during the trial run.

Edited by dancesintherain

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ages ago, before it was generic, I had to get slurroquel prior-authed. The insurance company didn't want to pay for it until we showed them failed trials on other aap's. But now its generic in the US and nobody cares really... and best of all, I don't need it any more.. :)

Edited by Wooster

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I got a prior authorization for Provigil and Nuvigil both (at different times) approved without a narcolepsy diagnosis, so...  there is hope.  I don't know what my pdoc put on the forms, of course, but it went ...  semi smoothly.

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