Patients and Physicians Speak Out

Medicare Advantage […] delayed responding to my PCP’s request for a prior authorization for a referral to a dermatologist to assess a small pigmented mass on my ear. The delay of 5 months was due to my [insurer] subcontracting the approval process to [another company]. It was two more months before I had a malignant melanoma removed, and it had grown more than 3 times the original size. I am now receiving immunotherapy. This may not have been necessary if it had been addressed when it was first detected.

I have treatment-resistant depression. My psychiatrist prescribed a medication that is non-standard after the standard medications failed. My insurance objected, but then agreed to let me try it. However, because the insurance required a new prior authorization every month (causing a 2-week delay in filling the prescription), I was unable to take the medication consistently due to running out of it every month, so I never received enough of the medication for it to have a chance of working. It was a lot of trouble, and I gave up, due to my continuing depression.

I work in a headache clinic. Most of our treatments, at this time, are "off-label." When I prescribe a medication that is denied, the pharmacist tells the patient that I just have to do a prior auth and they can get it. I (and my MA who spends 50% of her time doing this) completes the prior auth, however, the prior auth requires a stratified treatment based on the medication's FDA-approved indication. I explain and even include studies to show the potential benefit for headaches. The prior auth is denied and the information given to the patient, either by the pharmacist or by the patient's insurance rep, is that a) I didn't do the prior auth correctly, or b) it was not the right medication for that patient. Both statements seriously erode the patient's trust in my knowledge and ability to help them.

My son is 20 and has Crohn’s disease… The health plan insisted that he switch product brand, because of their insurance contract with said company. His immunologists from both coasts argued in writing and on the phone that since he has no antibodies to the antigens in that brand, it would surely cause an allergic reaction/hospital admission. This arguing lasted about 3 days - 3 more days of delaying carefully timed treatment that is helping him to stay in a sort-of remission state, by the skin of his teeth...It isn't wise and it isn't fair to add this burden to patients and their families, because living with and managing chronic illness is already fraught with many barriers. I am so exhausted.

I am an ex-nurse and a disabled veteran … I had a loose titanium knee and it took me almost two months to get surgery due to all the hoops & phone calls to get through. Because of the wait my loose knee had chewed up the top of my tibia which had to be replaced with some more metal after cleaning out the necrotic tissue & bone. There are real consequences to such a wait.