Patients and Physicians Speak Out

I’m a Type 1 diabetic who EVERY year has to wait for prior authorization for the same insulin pump and continuous glucose monitor (CGM) supplies I’ve been using for YEARS with the SAME insurance company and plan. This results in me going without, begging friends, asking the doctor for extras, etc. I’m switching to a new CGM and can’t get it preauthorized without the previous [prior] authorization being removed, which I’m told can take days. More delays, less good blood sugar control. I spend so much time on the phone — including HOURS on hold— because of [prior authorization] insurance baloney and get VERY stressed out, which drives up blood sugars. I’m used to advocating relentlessly for myself unfortunately, but I fear for the people who don’t know how to, or don’t have time, or believe what they are told even when it’s the insurance company that made the mistake.

My insurance quit covering my rescue inhaler and didn’t list any on the approved list, so I had to call them. [I] was given the names of two replacements, one of which isn’t working well for me, but the other requires [prior authorization]. So, until approved, I must use an ineffective medication to breathe!

Recently I needed a lifesaving blood transfusion. This required an ER visit. Because I didn't get "prior authorization," I am now stuck paying the cost of the ER. I am 100% disabled, live on less than $1,200 a month, and have had most of the bills go over to collections because I simply cannot pay them in a timely fashion. I would like to know how someone is supposed to get "prior authorization" for a lifesaving ER visit.

While waiting for approval for a heart surgery, my friend died of a heart attack!

Prior authorization places an extra step between physicians and patients, one which benefits the insurance companies, places the insurance company in a position of determining appropriate medical treatment on the basis of cost to the company, and is confusing and cumbersome for the patient, not to mention delaying the treatment. It is absolutely a matter of profit trumping people.

I am a senior citizen and a military veteran. My wife recently had an increase in one of her medications ordered by her doctor. [The insurance company] refused to fill the prescription as written, leaving her at 2/3 of the required dosage. The doctor filed the form for a prior authorization and [the insurance company] refused to honor it. As I was preparing a detailed appeal letter, we received a second letter from [the insurance company] saying that they approved the increased dosage. Had they not made the approval, my next step would have been to have the doctor write a prescription for the most expensive alternative medicine available (some of them approach $1,000 for a 3-month supply). Here's where the prior authorization went wrong in this case. The reason for approval was a clause in the contract between [the insurance company] and [the pharmacy benefit manager] that says [the pharmacy benefit manager] must fill prescriptions using the cheapest available method. Prior authorization is not always about medical need - it's all about the money.