Tuesday, August 09, 2005

HEALTH PLAN Prescription "Prior Authorization" Compliance Example

Note: This blog is a real example of my own situation. I am continuing to use myself as a model of what I am bloging in the Disabilitykey Website. I passionately believe that we can only achieve the best quality of life for ourselves if we become an Expert Patient; a Chronic Disease Self-Manager; and participate with our Doctor in a "Patient-Centered" health care plan. BUT, I can't cajole, push, encourage y'all to accept these philosophies unless I first demonstrate that I too accept and follow them! So, here's a real life example describing the application of all of these philosophies!

"Prior Authorization required before this Plan will pay for this medication." How many of you have read this statement beside one of your medications when you check them out as your Company changes Health Insurance Plan coverage? Hopefully you did BEFORE you went to the Pharmacy expecting to get your medications, same as before, only to find out that you had to pay full amount for a needed medication (usually the most expensive one - ever wonder why this always happens?!?)

AND, if you, like me, are taking one of the "in the news" pain medications like Vioxx, Bextra (wait - we can't take these any more, even if we wanted to!!) or Celebrex, the Health Insurance Company REALLY DOES NOT want you to take these meds, as they don't want to be sued if there is a resulting problem.

So, you call the Plan, and they say that your Doctor has to fill out a document "justifying" your need for this medication, and obtain prior authorization before they will consent to pay for the medication. And by the way, we (the Health Insurance Plan) really don't think that anyone needs to take pain meds; they can just take OTC (Over The Counter) medications like the rest of the world. So, Doctor, do your best to justify for your patient, but...

Unfortunately for my Health Plan, I am VERY STUBBORN (gee - do you think that y'all might just have figured this out for yourselves by reading these blogs???). I know that the pain meds help me, I have been using them for over 4 years, and my Doctor prescribed them for me originally because I was taking 2X to 3X the "regularly approved" amount of OTC meds, and he was worried about the impact on my stomach and/or liver.

BUT, I have been taking the medication (in one form or another) for over 4 years, and I can't really remember (scratch that - I don't WANT to remember) what I felt like before I took pain meds!

OK self, I say, you claim to be an Expert Patient; to be a Chronic Disease Self-Manager; and you claim that you and your Doctor participate in the new "Patient Centered" Health Care (I promise to begin blogging about this tomorrow!) You know what you have to do!

Yes, I DO know what to do, and this is what, in fact, I did. Please, I ask all of you, keep your fingers crossed that it works! As I just completed the process today, I'll keep y'all informed on the outcome.

So, I needed to know exactly what the Paim meds did for me, and compile a document for my Doctor to assist him in documenting the Prior Authorization justification form. So....

1) I stopped taking the Pain medication the end of June! You see, as an Expert Patient and as a Chronic Disease Self-Manager, I am the only one who knows my body, my symptoms, and how the meds that my Doctor prescribes to my impact those symptoms. I can't ask my Doctor to write up something without my input. He is a fantastic Doctor, but he is not a mind-reader.

2) I spent the entire month of July off of the pain meds, trying to decrease the level of pain using OTC meds. You'll see the document that I wrote for my Doctor later on in this blog. I kept a daily diary about what was going on in my body.

As an aside, my family and some of my friends thought I was CRAZY! They watched the impact on me of being in constant pain, and thought that I should just pay the full price and take the meds! But, that would have defeated the point! Why have health plan insurance if it doesn't cover what it should? I can't let the Health Insurance company "win" on this; what about all those others out there in my same circumstances who can't afford to "just pay the money and get the meds"? AND, how can I "preach" to y'all to take chances and take responsibility for your body and your actions if I don't do the same first, and lead as an example?

3) At the end of the l-o-n-g month of painful July, I prepared a document of my situation and faxed it to my Doctor along with a request for him to prepare the Prior Authrization justification for me. I also called the Health Plan, gave them my Doctor's fax number, and asked them to fax a copy of the Prior Authorization justication form to my Doctor.

Now, there are some very key concepts demonstrated in what I just said above, and all relate to the concepts of control, self-reliance, and self-responsibility.

  • First of all, I took total responsibility for this process. I decided to stop taking the meds and to gather the documentation, because I needed to gather information. Now please I DO NOT RECOMMENDING THAT YOU STOP TAKING KEY MEDICATION THAT HAS BEEN PRESCRIBED BY YOUR DOCTOR THAT IS KEEPING YOU ALIVE. If you are unclear about what you need to do, you can always call your Doctor and run by him/her what you plan to do, and get his/her approval.
  • Secondly, I let a whole month go by so that I could gather as much information as I could.
  • Before i had anything sent to my Doctor, I called ahead and left a message for my Doctor through his Assistant to be on the look out for the incoming faxes.
  • Even though I had covered the who, what, why, when, over the phone to my Doctor's Assistant, I also documented that information into a cover memo attached to the justification documentation I sent to my Doctor.
  • Next, I was the one who called the Health Plan and had the document sent to my Doctor, as well as my documentation and cover memo. My Doctor's Assistant called me back to tell me that she had received both faxes.
  • I asked her to fax back to me what the doctor wrote on the form so that I can keep a copy in my files.

See, there is a process, and I, as the Expert Patient, kept control of it with my Doctor's help.

4) In the soon-to-be-blogged information about the Patient-Centered health care, the PCP (Primary Care Physician) Doctor treats the whole person, not just a symptom or two. And, s/he keeps in contact with any specialists that his/her patient sees, so that the PCP and the patient are like in the center of this web of contacts, treatments, and processes - TOGETHER. My Doctor and I have been working this way for over 10 years - long before I knew that it was really a process to be emulated! So, here's the document that I sent to him.

July 31, 2005
The following documents the pain that (I) suffer on a daily basis without a prescription of Vioxx, Bextra, or Celebrex. I have been on one of these three NSAIDS, Cox-2 inhibitor (selective) prescriptions for pain for over 4 years. As a result of a recent health insurance plan change, the plan requires that my Doctor justify my need for this prescription before its use can be approved, therefore, covered by the prescription coverage part of the health insurance.


When I called the health insurance company to ask about the justification, I was told that the Doctor needed to write out the justification on their appropriate form, justifying the need. The health insurance would review the justification, and determine if my need met their guidelines for coverage approval.


It is my understanding that the usage “justification” must demonstrate, to a medical necessity, that the need is greater than relief provided through use of OTC (over the counter) pain relief medications. Since my Doctor, needs to make this justification, I knew that I needed to supply him with evidentiary proof so that he could write the justification. Although (my Doctor) is the absolute best PCP (Primary Care Physician) possible, he is not a mind reader. Hence, he can only use what I provide to him.


Since I have been documenting my Multiple Sclerosis symptoms in the Attached Symptom Impairment Matrix while taking either Vioxx, Bextra or Celebrex, I knew that I had to get off of the pain medicine and actually take an OTC medication to be able to report on the impact that pain has on my Multiple Sclerosis symptoms to my Doctor. So, I ended my Celebrex medications on June 30th, 2005. I have now been relying solely on my other medications

[1] and the OTC pain medication of extra strength Non-aspirin Acetaminophen; caplets of 500 mg each. It took just 2 days without my daily Celebrex for the pain symptoms to begin to emerge. I have now had a month to document the results of my research into the impact pain without my prescription pain medication has on my Multiple Sclerosis symptoms. The following describes my symptoms and their impact on my body and my normal daily activities.


1) First of all, when I take the acetaminophen, I have to take 4 tablets, each time. This exceeds the recommended dosage, and, to even attempt to have any impact on my pain, I have to take 4 tablets every 4 hours, or a total of 24 tablets per each 24 hour period. This dosage level exceeds the recommended dosage level (the recommended dosage is not to exceed 8 tablets in a 24 hour period). I am concerned about the impact this level of dosage of acetaminophen is having on my stomach and liver. As of today, after 28+ days of this regime, I am experiencing daily stomachaches, cramps, and diarrhea.
2) As you can see in my attached Multiple Sclerosis Symptom Impairment Matrix, I deal with some level of pain on a daily basis, even while taking my prescription pain medication. However, I never realized just how well the prescription pain medication allowed me to better manage my other bodily functions until I went off of the prescription medication. Here are my ADDITIONAL PAIN IMPLICATIONS even taking the 4 acetaminophen tablets every 4 hours.
Ø My lower back aches all the time, with pain shooting down my legs. While on pain medication, this symptom occurred occasionally, NOT ALL THE TIME. My doctor says that this might be sciatica pain. This pain makes walking, climbing stairs, turning; all slow, jerky, and painful.
Ø My head, neck, shoulders, arms, hands, torso, back, hips, legs, knees, ankles, toes all ache, all of the time. The bones ache – deep; the muscles ache – throb; and, the muscles shake. This constant pain makes me clumsy, awkward, slow, and each movement hurts. As a result, I have fallen more often this past month then I have in the past 5 years! I have the bruises and scabs to document the falls. Even my son, with whom I live in a basement apartment, commented on my increased clumsiness.
Ø As a result of all of the pain, going to the bathroom is an event that is terribly painful. I have to move my arms and torso to carry out the activities, and each second hurts!
Ø I am more tired this past month than I have been in the past 4 years.
Ø Compensating for my constant pain increases my reaction to heat this past month.
Ø I have had tension headaches every day this past month; I had only about one or two per month on the prescription medicine.

Please approve my Doctor’s request for me to be able to once again take my prescription pain medication!
Thank you.


As you can see, there is lots of detail in the above document. I'll let y'all know what the result is.

Best of luck in your own documentation. Again, if you have questions or comments, please add to this blog, and we'll share with everyone!









[1] In addition to my pain medication prescription, I also take Gabapentin (300 mg capsules) 2 capsules by mouth 2X per day; Baclofen (20 mg tablets) one tablet 3X a day; and, Paroxetine (40mg tablets) one tablet 1X a day.

1 Comments:

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1:06 PM  

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