Patients and Physicians Speak Out

HealthNet, my insurance since 2010 who has never denied anything, suddenly stopped covering Rinvoq, the only Rheumatoid Arthritis medication that has work for me since I was diagnosed in 1999. I had already been taking it for several months and in January 2025, suddenly the prior authorization information they requested was not sent (yes, it was, 3 TIMES). I have been without my meds for 3 months! What happened between December 2024 and January 2025? My Doctor of 20 years is just as frustrated with the runaround. Next step is reaching out to Insurance Commissioner and seeking legal representation.

We found out our son has asthma after two frightening trips to the emergency room (ER}, followed by days in the hospital when he was four years old. The doctors prescribed Flovent as a maintenance treatment to help keep his airway clear and prevent return trips to the ER when he would get an illness. The first time I tried to pick up this medication I heard of “prior authorization.” I thought, “What does this mean?” The doctor prescribed it, so why does an insurance company get to decide whether it’s required? Luckily, the doctor was able to get it approved quickly. The next time I tried to pick it up, it was the same - why would they need to approve it again for the very same medication? This time, I ended up paying out of pocket because I needed it that day to continue treatment. Over the past two years, he’s been using this [medication] and I’ve been held up at least half a dozen times for prior authorization for the same medicine for the same ailment - it has not changed!! Why does it have to continually get approved? With the new plan year, we may have to move to a different medicine, which is incredibly unfortunate for a young child to have to switch from something that is working to an unknown.

Prior authorizations routinely delay patients being able to see me and to get radiologic and other studies done in a timely fashion. I am a gyn oncologist, and I have seen patients with cancer wait for months to get an appropriate referral to a gyn oncologist. One recent cancer patient of mine waited 6 months to see 3 physician specialists for surgery. Once she had seen them and set up her surgery, her scan was repeated (she had to wait a month to get this approved also) and she had disease progression and was no longer eligible for surgical cure. This patient was 27 years old. I had to call her and tell her we needed to cancel her surgery. She may never be eligible for curative surgery again. This delay most likely significantly worsened her prognosis and will contribute to a family losing their daughter, wife and mother. This needs to end now.

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!

I have narcolepsy. There is no cure, but there is a medication that lets me live a normal life if I follow its precise schedule. It is the only medication of its kind, because of patents, and it costs thousands of dollars for a week's worth of medication, because there is no generic competition. I am forced to get this medication through insurance, or I would quickly go into debt just trying to stay awake and have a normal day. I have recently switched insurances. There will be a four-month gap between when I lost my old insurance, and when I will be able to see a new sleep doctor to re-prescribe the same medication. Then there will be extra delays as prior authorization decides if I am allowed to have the medication necessary to let me drive safely, hold a job, and experience life without constant debilitation.

I have been rationing my sleep medication, hoping to make it to the sleep doctor before it runs out. I am actively sabotaging my own health, hoping the system deigns me worthy to continue receiving care in a relatively timely manner, before I am non-functional. But soon I will be forced to switch insurances again--meaning a doctor visit, and a re-prescription, could be even further away, and my health may deteriorate further as I wait. Every day I do not take my medication, is a day I do not get restful sleep. After two weeks of not taking my full dose of medication, I would be unable to drive safely or perform at work. American healthcare, and prior authorizations, are forcing me to either go into debt, or put my safety and my job at risk.