Patients and Physicians Speak Out

My daughter had a tonsillectomy as an adult (notably more difficult recovery, they say), and the pain medication she needed was not available at the pharmacy because it needed “prior authorization.” The option was to either give me a few days of it and I fight for more, or I pay out of pocket for pain medication POST SURGERY.

I have been battling irritable bowel syndrome with diarrhea (IBS-D) for over 12 years. I’ve had three colonoscopies and one camera that I swallowed, as well as many other tests over the past few years. I went to a new gastroenterologist who looked over my records and said I have IBS-D and prescribed a drug that they claim will take care of this. It has been weeks since the doctor’s office filled out the prior authorization and nothing. I assume it has been denied. I cannot go anywhere far, including work, on certain days. I am debating on going to the emergency department to get some relief. I know this cannot be cost effective for me or the insurance company.

I have two children who have type 1 diabetes. I can’t tell you how many times my oldest son had his insulin or pump supplies denied because they [insurer] needed prior authorization for a medicine that had already been established as necessary for him to stay alive and yet, year after year, they hold up his prescriptions at least once saying they need prior authorization. Do they realize there is no cure, and he will need those medications and supplies forever? My daughter was just recently diagnosed and was dangerously close to going into ketoacidosis. But the insurance company needed prior authorization for a glucose meter and her insulin was held up for 24 hours because the insurance company needed the doctor to call in a prescription of the generic version of insulin, instead of giving the pharmacist or me the option to say, “Yes, I want the generic version.”

After chemo for jaw bone cancer, my husband was scheduled for a mandibulectomy & fibula free flap surgery. The surgeon indicated minimum (best case) hospital stay would be five days. Aetna pre-authorized for only a three-day hospital stay. On the third day, they did nothing to see if it was necessary to authorize additional days. I was a Workers Compensation Adjuster. I know that these should be authorized based on medical necessity. I asked the Aetna nurse assigned if they could find a single example of someone who had this surgery only needing to be in the hospital for three days and explained that if they could not find even a single example, their decision was a business decision based on profit and not on medical necessity. On day three I was on the phone, yelling at them that they needed to extend the authorization. Instead of visiting my husband in the hospital on day three, I was on the phone with them all day.

I’ve had type 2 diabetes for 15 years. I have been on various diabetic medications during that time with numerous side effects. When my doctor prescribed Ozempic two years ago, it was a game changer. My [hemoglobin] A1C is finally under control. Up until this year, my [Medicare] Part D plan has covered the medication, although copays have been high. Now, I wait for someone at my insurance company to make a decision that affects my health. What happened to that decision being made by the patient and physician? Prior authorizations are taking medical decisions out of doctors’ hands, adding costs to their practice and delaying patient treatment.

Being a type 1 diabetic, I need insulin pumps and glucose testing supplies. I have been using Omnipod Classics for almost 10 years. The company that I now work for had a health insurance option, HealthNet of Oregon. They immediately rejected my Omnipods because they weren't a necessity. I started paying out of pocket for Omnipod Classics and Dexcom G5 continuous glucose monitoring (CGM) system. I eventually dropped the Dexcom and started testing manually, because I could not afford $3,000 for a 90-day supply. 

I ended up spending over $10,000 on credit cards trying to keep my Omnipod supply. In late 2022, I found out my Omnipod Classics were being phased out, so I needed to upgrade. I tried for a whole year to get them approved. My doctor’s office goes through every hoop to send preauthorization paperwork only to have it denied with the reason being ‘not enough info.’ 

My doctor’s office sent copies of emails with lengthy explanations and records proving the necessity. It wasn't until Healthnet appointed me a case worker that I got a year-long override to have Omnipod 5 and Dexcom G6 CGM system. Now, in 2024, I am still fighting to be reimbursed for the out-of-pocket expenses for medications that should've been approved from the start.