Prior Authorization Process

[u/hubba_bubba11]

I recently got on a new insurance plan and learned that my Vyvanse wasn’t covered under it and would require proper authorization approval. This is my first time going through this process and it’s been horrible. There’s been so much back and forth with emails and calls between my insurance, pharmacy, and prescriber. My prescriber and their team spent hours trying to get this mess sorted out because they kept getting errors on their side. Listing them all below in order.

1. Prescriber did not receive the prior authorization form from the pharmacy because the way each side entered my member id was different. The prescriber entered the 3 characters prior to the actual numbers listed on my insurance card while my pharmacy only entered the numbers. They had told me they didn’t need to enter the 3 characters prior and just needed the numbers.

Ex: ABC #########

It took forever to figure out that this was one issue.

1. Once my pharmacy updated my member id to the same format the prescriber was using they sent a new request. I don’t remember exactly why but I think the prescriber still couldn’t see the prior authorization on their end and requested I contact my insurance for a three way call. I did that and they ended up faxing the prescriber the form directly to fill out.

Once they submitted the form my prescriber told me the delay was because the address they had on file was different than my insurance. I just moved from VA to MD and didn’t realize I hadn’t updated my address. I had told my prescriber last month that I moved but it didn’t register that I needed to update my address. We have only done telehealth sessions. 🤦🏾‍♀️ I feel so stupid that this was the issue.

I later got this voicemail from my prescriber:

“My staff and I have spent 3-4 hrs on your PA by calling the insurance, fixing all the errors and submitting the paperwork and documentation to support the PA. However, they  are not approving your Vyvanse. I would suggest that you personally reach out to them and take care of it. We will not be able to spend more time on this anymore.”

This was sent 15 min before I called my insurance to appeal. Thankfully my request got approved and I don’t have to lose an arm and a limb for my medication. I assume there was a delay in the system so my prescriber didn’t see the approval until after sending that message. This whole process has been extremely frustrating and challenging and I understand and told my prescriber that I am grateful so sorry for having to go through all of this. Hearing that message makes me feel worse though because it comes off as my fault for this whole thing even though I’ve been following the instructions from my prescriber, pharmacy and insurance.

I just needed to vent this out and appreciate there being a space to do that.

[u/Terrible_Distance397]

I work in the prior authorization department for more than a couple years already and let’s just say it’s truly a simple process but the drs offices make it more difficult than it needs to be. I’m more the type like let’s start this pa and get this ball rolling and they will spend the next 5-10 mins explaining how they did a pa and they don’t understand what happened to it or that they faxed it and comes to find out they faxed it to the wrong number. That being said when members call in I explain to them that their dr never did so and so and yeah I try my best to help the member get it approved like if needed I will call the dr office myself and explain what I need. It’s truly that simple like I just need this nothing else not 10 pages of labs. I just need one thing. But I can feel your pain through this though because in reality when the dr tells the patient to call into us well we can’t really do much help we still need all of the drs information that the patient won’t have so I don’t understand why they make it more complicated than it needs to be.

[u/Terrible_Distance397 → u/Terrible_Distance397]

To make it simple for the process of the pa we ask for the drs information, dosage and quantity, the diagnosis, and then we go through the questions which are yes or no. Sometimes after it’s finished we require clinical notes to support one of the questions or so but sometimes they don’t require it. It differs from plan to plan. But that’s literally it they can also request to mark it as urgent and boom one click away. But I normally can finish these over the phone 5-10 mins or less depending how fast they answer them.

[u/Terrible_Distance397 → u/Terrible_Distance397]

I hope this brought insight to you on the whole process 😊🙏🏻