Prior Authorization

“That'll be one thousand blah blah dollars. Do you want to complete your order?”

My brain shut down briefly after the “one thousand,” rebooting in time to hear the “dollars.” No, I didn't want to complete my order.

I was trying to refill my prescription for anti-seizure meds. The problem was that I wanted the brand-name.

In general, generic is not the same as name brand. The active ingredients are required to be identical, but the inactive ingredients, such as binders and time-release agents, are not. The time release aspect of the medication can be crucial to its effectiveness.

In addition, often, more than one pharmaceutical company produces any given generic drug, and when it somes to generic meds, pharmacies can switch companies without warning. In other words, they could switch meds from refill to refill.

The thought of switching anti-seizure meds terrifies me—seizures can kill.

When there was no generic version of the drug, my prescription insurance covered it. However, once a generic became available, the insurance stopped covering the brand-namea thirty days' supply would have cost me more than a thousand dollars.

Luckily my pharmacist was incredibly helpful, and after he spent what seemed to be a lifetime on the phone, he pointed me in the right direction—I needed to ask my doctor to request a brand-name drug prior-authorization from my insurance company. After much ado, I obtained the prior-authorization, and was able to purchase a thirty day supply of the brand-name anti-seizure meds for forty dollars. I had to renew the authorization regularly, which I did with no trouble.

Come January of this year, I changed my health insurance company, but my prescription insurance company stayed the same. But I didn't realize that the two are tied together. When I phoned the drug company to refill my prescription, I assumed that the prior-authorization I had just renewed was still in effect. It wasn't.

I phoned my neurologist. “Our menu has changed, so please listen carefully for the options.”

I tried several different options, but I couldn't find a way to get through directly to Kelly, the nurse practitioner who usually took care of the prior-authorization. But no worries, I had an appointment with my neurologist in a couple of weeksand I still had plenty of time. I'd wait until then to speak to Kelly.

Kelly assured me that she'd see to it.

I wasn't concerned when drugs didn't show up within a week. Nor was I worried two weeks later. But just in case, I phoned the pharmaceutical company. They'd heard nothing. I phoned the doctor's office, and once again went through every option, the drug-refill option, the appointment-making option, the speak-to-a-nurse option—I got nothing but automated responses—press this for A and press that for B—nothing I pressed led me to a person. There was no other choice, I would have to pay the doctor another visit.

Just before venturing out, I decided to try the phone one more time.

Pressing the option to speak to a nurse, I actually got a nurse, a real, live, warm blooded nurse. I was in shock. I umm... Hi umm... My name is...” It took me a few seconds before I was able to explain the issue coherently.

Apparently, Kelly had misunderstood me, and had sent out a request for a refill rather than a request for a prior-authorization.

I had three and a half weeks to go before I ran out of meds. Antsy, I phoned up the pharmaceutical company. “Yes, the prior-authorization came through. It'll be a week before we process it, then another week or two before we mail the meds.”

There was still a chance that I'd get the meds in time, but... Perhaps I should ask my pharmacist to sell me a few pills to play it safe...

I decided to take the chance. Partly because I knew it wouldn't be straightforward to get a few pills and I just couldn't face any more hassles. But mostly because something inside me enjoyed the idea of playing chicken.

I'd just taken my last morning dose, I only had enough for my evening dose. Around lunchtime, the mail arrived, and with it, my pills.