Drug Rx Needs PA

somarco

GA Medicare Expert
5000 Post Club
36,847
Atlanta
Recently a Doctor Peter, MD, donned a blonde surfer style wig and his best California surfer accent to reenact his first time having to call in a prior authorization. A prior authorization is often needed when a doctor prescribes a medication that the insurance company deems unnecessary. No, the insurance companies are not doctors nor are they the patient needing the medication but they have a list of approved medications they're willing to cover. If the medication you're prescribed isn't on their list, it sets of a frustrating chain of events.

 
I don’t know of any MD’s calling in the PA. Nurses, yes.

True that . . . but regardless of who is performing that task, it still remains that " insurance companies are not doctors nor are they the patient needing the medication"
 
I recently saw the video and had a somewhat different take on it, and as you know, I started in this business before networks, prior auths, etc. were around.

This goes back to a comment our old mony manager said to me about expenses on the road. My first business trip in 1983 I asked him how do I know what expenses are valid and what amounts. He said to me "if you would buy it for yourself, then buy/expense it on your trip". This was especially true of hotel rooms.

Now fast forward to this video. I agree it does show the frustrating aspect of our healthcare system. But I would turn it around a bit and present it to the patient as "You can have the drug, but it will cost you $x, but if you like we have alternatives that you can have at a lesser cost". Chances are the patient will almost always go with the lower cost.
 
"if you would buy it for yourself, then buy/expense it on your trip".

I worked with a couple of guys who thoroughly tested the water on this "rule"

One guy took several suits with him and had them dry cleaned at company expense even when he was only out of town for a few days.

That same guy charged aspirin to the company because he had headaches he claimed he would not have if not for the job. He also bought an umbrella on every trip and even a few nice London Fog raincoats.

Another fellow played golf as often as possible and treated his brokers to a golf outing. Each time he bought golf balls, tee's, gloves at the club house and billed the company for these items as well as the green fee's, cart rental and of course the 19th hole refreshments. Some of these purchases were made when his manager was in the club house and gave tacit approval.



And yes, most folks, myself included, buy generic drugs if they are as effective as the prescribed brand name.
 
I worked with a couple of guys who thoroughly tested the water on this "rule"

One guy took several suits with him and had them dry cleaned at company expense even when he was only out of town for a few days.

That same guy charged aspirin to the company because he had headaches he claimed he would not have if not for the job. He also bought an umbrella on every trip and even a few nice London Fog raincoats.

Another fellow played golf as often as possible and treated his brokers to a golf outing. Each time he bought golf balls, tee's, gloves at the club house and billed the company for these items as well as the green fee's, cart rental and of course the 19th hole refreshments. Some of these purchases were made when his manager was in the club house and gave tacit approval.



And yes, most folks, myself included, buy generic drugs if they are as effective as the prescribed brand name.
These guys sound like certain Drs. and nursing homes when they see someone has OM and a Med Sup. Let the free for all begin!
 
Recently a Doctor Peter, MD, donned a blonde surfer style wig and his best California surfer accent to reenact his first time having to call in a prior authorization. A prior authorization is often needed when a doctor prescribes a medication that the insurance company deems unnecessary. No, the insurance companies are not doctors nor are they the patient needing the medication but they have a list of approved medications they're willing to cover. If the medication you're prescribed isn't on their list, it sets of a frustrating chain of events.


This whole thread seems a bit weird.

One doesn't need a PA for a formulary exception. He (or his doctor) needs to ask the carrier for an exception, not an authorization.

PAs are only needed when required by the formulary for drugs that are already covered.

Reminds me of a thread a while back where I was batting my head against the wall trying to convince a certain agent that one files an appeal, not a grievance, when contesting an adverse coverage determination. I gave up when I saw another post where the guy referred to "credible" (believable?) coverage. It was hopeless.

Not trying to be a jerk, folks. Terms matter in this business. If you don't believe me, tell a secret shopper he will get "free" doctor visits, and watch what happens.
 
If you don't believe me, tell a secret shopper he will get "free" doctor visits, and watch what happens.

I suppose you also have a problem with . . .

FREE colonoscopy
FREE annual exam
FREE dental
FREE vision care
FREE Rx tier 1 only
FREE Part A
FREE Medicare plan

As for your other objection, the quote is from the link, not MY words.

And I don't have a blonde surfer wig
 
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