Using the PA (Prior Authorization) Process to Deny Necessary Medication

Using the PA (Prior Authorization) Process to Deny Necessary Medication

By Steve Ariens, PD.

Retired pharmacist and chronic pain advocate Steve Ariens has some tips for chronic pain patients in fighting their insurance companies.

As we enter a new year, many PBM (Prescription Benefit Managers) and insurance companies are using the war on drugs and “opiate crisis” as an excuse/reason to cut back on the coverage of pain medications and other controlled medications. Some believe that it is primarily to help boost their bottom line profits, while others believe that it is an effort to head off being sued by various cities, counties, states and others … like they are now suing the numerous pharmaceutical companies and pharmacy wholesalers. The tactic has been used before – they are much like the lawsuits these same/similar entities did in the late 1990’s to the Tobacco industry resulting in a $200+ billion fine to that industry.

Steve Ariens

Placing a medication on an insurance company’s formulary plan gives the patient the impression that a particular medication is covered until the “asterisk” behind its name indicating that it simply requires a Prior Authorization (PA) in order to get it paid for. Often the hoops/hurdles/obstacles that have to be cleared to get a PA approved are obscure or less than transparent–making it time consuming or nearly impossible in getting a “PA medication” approved. Some PBM’s/insurance companies will use both a PA and QL (Quantity Limit) to restrict a patient’s access to particular medication(s).

The practice of medicine has some rather simple basics. All prescribers are licensed at the state level and all state medical practice acts require that in order for a prescriber to establish a treatment plan, they must first do a IN PERSON PHYSICAL EXAM. Once that exam has been done the prescriber then can legally proceed to develop a patient treatment plan for the patient.  The practice of medicine is simple – examine the patient, diagnose any health issues, develop a plan of treatment is designed to treat/cure, and/or manage/maintain the issues associated with the patient’s various health issues. These basics become very important as the insurance/PBM industry tries to utilize PA’s and QL’s to impose their wishes on the various medication treatments.

Basically, there are three types of health insurance, individual/small employer policies, ERISA self-funded employer policy and Medicare/Medicaid. Because the vast majority of chronic pain pts are on Social Security/Medicare disability, Medicare/Medicare Advantage, or Medicaid. This article will focus on those, but there are many similar paths that a patient can take with the other health insurance policies.

What patients may not know- and be assured the PBM/insurance companies will not tell you unless you ask…that there are FIVE LEVELS OF APPEALS:

Your Medicare drug plan will send you a written decision. If you disagree with this decision, you have the right to appeal.

Level 1: Redetermination from your plan

Level 2: Review by an Independent Review Entity (IRE)

Level 3: Hearing before an Administrative Law Judge (ALJ)

Level 4: Review by the Medicare Appeals Council (Appeals Council)

Level 5: Judicial review by a federal district court

There are links to the details of these appeal processes.

The patient needs to contract the PBM/Insurance, regarding the approval, especially if they miss time deadlines. If nothing else, tell them that you want to get to the next appeal level if they are not going to pay for it.  Knowing that a patient is going to be aggressive in the appeals process, may get them to give up and approve the medication.

The patient can expect to have the first appeal denied, because it is being reviewed by the same employees that put the PA/QL in place. The easiest and most profitable thing for the PBM/insurance company to do is SAY NO.

Remember it’s frustrating for them is the patient keeps appealing. They know that the farther the patient takes the appeals, the more likely they will get approved and they will have to pay for it. The whole PA/QL process is to frustrate the patient and get them to “give up and go away”.

A patient also has the option of stating that they require a “emergency determination” which means a decision has to be made in 72 hrs.  For instance, if the patient has been maintained – and physically dependent – on an opiate, he or she could be thrown into cold turkey withdrawal… not to mention the normal side effects of untreated elevated pain, nausea/vomiting, sweating, stomach cramps. They are also at risk of a hypertensive crisis that may lead to a stroke which could lead to permanent paralysis and/or death.

If the PBM/insurance wants to change the medication that has been working for the patient and/or reducing the daily dose – you can argue they are attempting to practice medicine without a license. How they will try and get around this by getting the patient’s prescriber to “agree” with their limitations… which takes the “practicing medicine without a license” off the table for the insurance/PBM.

The doctor has a role to play. If the patient’s prescriber refuses to “go along” and then PBM/insurance continues to insist on changing the medication that the patients has been stable on… then they are entering the practice of medicine without a license arena.

All of these PBM/insurance companies have a “medical director” on staff.  One could assume that if someone is attempting to change a medication the only person on the company’s staff that could sign off would be the company’s medical director.

Of course, the medical director has not done a in person physical exam on the patient (the patient is simply a name on a computer screen) and quite likely does not have a license to practice medicine in the state in which the patient lives.

It may be appropriate at this point to send the Medical Director and the Legal Department of the PBM/insurance company a certified letter stating that the patient is going to file complaint, including unprofessional conduct, with the medical licensing board in the state the prescriber is licensed in and the state in which the patient is residing……unless the PBM/insurance company approves payment for the medication which the patient has been stable and maintained on for some time.

It may also be appropriate to file a grievance with www.cms.gov 800-MEDICARE against the PBM/insurance company claiming that their decision(s) is going to cause the patient to become house/bed/chair confined, adversely affecting a patient’s quality of life.

One issue that patients caught in this PA/QL “trap” needs to be aware of is that the DEA considers it a RED FLAG for you to purchase controlled meds and pay CASH when they have insurance.  I have no confidence in the DEA looking at the issue that the insurance refuses to pay for the controlled medications before they could consider taking actions against the patient, prescriber, pharmacy involved.

If the patient decides to pay cash for their necessary medications, make sure to keep the receipts and file them with the PBM/insurance for reimbursement.  They might just “screw up” and reimburse the patient. If they do, keep a copy of the reimbursement for the appeal process to show how inconsistent their policies are.

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There are 36 comments for this article
  1. Rita KIMBEL at 6:53 am

    I’m so lucky to have the pain management doctor I have. He has gotten me 80 % pain free since the oxycontin cut off last year. I now worry if the meds I’m on now will be removed. He has been keeping me below the CDC recommendation with 2 different opiates, my neuro-stimulator and now waiting on my medical marijuana license for CBD oil. He is an extremely busy doctor these days, I see him once a month as required and my meds come hand delivered by the pharmacy. Everything is documented and signed and legal beagle, even the random urine tests. He is playing by the rules he must or else?

  2. Terry at 2:09 pm

    So I loved your post. It really doesn’t matter though. I feel your anger and frustration and my so called “pain management doctor” cut my meds way back, I have CRPS among ten other painful issues, but what can we do? I would sue the [edit] out of this quack if I had resources. He got me addicted to five 15mg oxycodone IR and three 40mg oxycontin ER per day for the past five years, and he cut me back to three 10mg percocet and two 40mg oxy per day, and yes my body is just a huge mass of pain every hour of every day. My doctor is just an anastasiaologist, he doesn’t have any other knowledge as far as I can see, his name is Viji Thomas at Gilead Pain Management, avoid him at all costs. He has the bedside manner of a stump and he is reckless in his practice. He is in Clinton Twp. Michigan. He has ruined my life, I can barely function anymore. He said the only exception for more pain meds would be cancer. I looked cancer up on the McGill pain index, http://www.rsdhope.org/mcgill-pain-index—where-is-crps-pain-ranked.html, and it has CRPS ranked as number one for the worse pain, even higher than cancer or losing a limb. My “doctor” told me that the only exception for getting more pain meds is if you have cancer, so with that criteria you would assume that a condition that rates higher on the pain chart would also qualify. Alas, it is what it is and I have no recourse. I have nothing left in the tank to fight with.

  3. R. Michael Maddox/ proud suffering Veteran USN at 8:16 pm

    One thing that I feel would really turn this around is finding some Lawyers with Nads. That will take this fight to court. It is Malpractice to turn your back on a suffering human. I understand that most doctors are just scared for their medical license. But all these docs have to do is proper testing to warrant the meds. Keep meticulous records of tests, MRI and such. It legally does not matter how many patients or prescriptions a doc. has or writes. As long as he can document and Prove that he is doing RIGHT by his patients, they may “F” with him but nothing legal will stick. Next file lawsuits against any DEA agent for practicing medicine without a license. The DEA is way overriding the CDC “Recommendations”. The CDC has written NO laws against Opioids. Every report from CDC in the last 8 years has pointed to the FACT that Less Than 1% of OD’s are pain patients with legally written prescriptions. I have watched the V.A. commit PURE TORTURE against our nations HEROS, by STOPPING, NOT TAPERING, Discontinuing patients pain meds. The only recourse these brave men and women have is either seeking out street drugs for their pain or eating lead. My Brother in law has RSD (CRPS) with hardware all through his spine. His V.A. doc, just cut his Morphine and Hydrocodone in HALF. Telling him that those meds will KILL HIM. He pointed out that as humans, we are dying from the day we are born. I get more than twice what he gets. But thank Gog, I have the most compassionate doctor at our V.A. Med. Center. He retired in Sept. But works part time 3 days a week due to doctor shortage. I am terrified of what will happen to my pain management when he leaves for good. In my opinion, the V.A. started this Opioid Crisis Crap. They needed a way to get the public eye off the fact that Vets, were dying due to the wait List Scam. they were working. So slight of hand they changed the narrative. Vets weren’t dying because of waiting years for treatment, They were dying from Opioids. Not mentioning THEY got all those Vets, addicted to the Opioids. My 90mg. Morphine daily and 30mg. Oxycodone daily and 1400mg. Soma daily do help with my ability to tolerate my pain. An accident unloading a Chemical Tanker truck in 1992 left me with a broken neck and severe chemical burns. Two surgeries later, Bunches of Titanium plates and screws I live in constant severe pain. More surgery needed, NO!. But vertebrae are crumbling, I feel as a result of Carcinogen Chemical exposure. Took 2 years to get V.A. to approve last surgery, even with 2 MRI’s showing severe spinal cord pressure from bones. By time I got to civilian Neurosurgeon, he said was a miracle I wasn’t paralyzed from neck down. About was. Left arm useless due to long term crushing of nerves by the bones. Anyway, sorry for rambling. I just feel that their are so many stories and people that are worse off than myself, and I cannot understand how a physician can work so hard to become one, and then turn their back on people that are suffering, all the while knowing VERY WELL they could help these people. Find lawyers. hit them in the wallets where they feel it. “First Do No Harm”. is first line of Hippocratic Oath that they ALL swear to. Allowing a human being to suffer needlessly IS DOING HARM !! I fail to see how these doctors can sleep at night much less look themselves in the mirror, without puking in disgust. Thank you all, keep fighting, NEVER GIVE UP. Have a Blessed day

  4. Tim Mason at 10:15 am

    Derek, Sounds like you are in dire straights, Your doctor should write you an Rx for a Rollator with seat to use instead of a cane,
    Google Cherry Pick and Lemon Drop AMA. There you will see where doctors have deemed it NOT unethical to treat a patient such as yourself,
    Physicians do not want black marks or a black eye for trying and failing. The AMA article mentions people with comorbidities
    there are some rehab places that work on your lymphatic system in your legs to get that fluid moving in your legs,
    We must keep moving even if it is baby steps, I feel every step I take and my mobility is limited as well.
    I was also told by three doctors that there was nothing else that could be done for my back.
    I guess if I were in your shoes I would try a physical therapy place associated with a hospital.

    Tim

  5. Derek Myles at 2:57 am

    Hi i really need help I want to be in the fight but I literally don’t have the physical and mental stability and abilities to function…I’m basically bedridden most days for 16 hrs or more laying in bed or in a recliner because I need to keep my feet and legs elevated for one of my latest health problems and conditions that is on some days the condition that causes me the most severe pain which is always constant and not acute ..and everyday I find it harder to be able to walk at all with out my cane and I believe I, gonna need to switch to a walker cus It just has proceeded to worsen with time ….my blood flow is so poor that my legs are the color of purplish and red…and have extreme swelling where i feel like my skin is being stretched so much my toes are gone break off like a piece of peanut brittle …most day. I can barely walk and put pressure on my legs to get out of bed by myself … ..I have seen cardiologist and there is nothing that can be done really to fix this problem …I’m permanently disabled on Medicare parts A, B , and D and because I’m basically indigent and of such low level income I’m part of the LIS rider program so I don’t have to pay for premiums out of pocket ..ive been on long term disability for many years now as I remember when I went through the 2 year process of being disabled on Medi-cal before being upgraded to Medicare and then have medi-cal as a supplementary to cover the 20% Medicare doesn’t .. ..I’m also on Social Security Disability benefits and I get $ 1107.00 to live on a month in Socal ..I suffer from multiple mental health and physical conditions that require high dosage of opioid medications for chronic pain. My initial introduction to Opioid medication was in 2011 I had a freak accident at Gold gym ..I use to lift heavy and train hard with free weights while I. Was finishing my BA… I remember the day like no other …I was doing squats with 300lbs and I lost my grip and the weights dead weight freefalling landing on my neck and back. I remember my initial doctor saying any average person would have been decapitated most likely and died instantly but thanks to having a the massive muscular body from training for many years it absorbed the damage( a comparison would be the USC football player who dropped 275 on his throat …around the same time i had my accident .but I never been the same since that day and every day I’m in constant pain that is irretractable …and their is no cure for…I have tried everything from physical therapy to chiropractors , acupuncture, epidural injections …( to the point of Dr abusing me and doing more damage then good for my back and neck literally giving me epidurals every 2 weeks alternating from neck to back …for. 4 years straight Kaiser only allows four a year I have documents in writing to prove it…and because of not wanting to keep doing them I was terminated …now I was started on a smaller dosage and finally years later stabilized on high dosage …however now the shift has changed so much in the medical community I have tried to find a new pain Management specialist.referred by Medicare website and literally 0 for 20 would take me on as a patient …most wouldn’t even look at my records or talk to primary doctor and thank god for my primary doctor whose care I have only been in now for 18 months because I most likely would be dead if it wasn’t for him cus he has been the only doctor willing to look at my paperwork before passing judgement on me and actually seeing that my medical condition has been well documented and verified since onset of injury but now I get hit with PA and he’s afraid of losing his license…but doesn’t want to abandon me either …I have an Ihss care taker provided me and I had all my student loans forgiven due to my condition after a long hard process of. Over 3 years of monitoring and plenty of paperwork documented by previous doctors who had been treating me in the past and only were changed due to no longer taking Medicare patients when. Obama care went into effect and then also because of my income I have had to move around to rural outskirt communities to be able to afford a place to live only to not be able to get treatment for my chronic conditions ….and to tie Into article my primary is succumbing to the hysteria and doesn’t want to be bothered with prior authorization as he really wants me to find a pain doctor yet I can’t …so what am I supposed to due with my history …conditions …killl myself …please include In California.. why are my patient rights being trampled on and where are the supposedly advocates that were created in order to protect the poeple like myself that can’t fight for themselves due to our health and mental illnesses and physically disabled conditions …PLEASE ANY HELP IS APPRECIATED

  6. Cheryl Russo at 10:59 pm

    Most doctors (or should I say the Physician Assistants) don’t want to be bothered with doing anything out of the ordinary in writing prescriptions. I have 1 PA who gives me such an attitude when I call her to let her know the insurance company needs something different in the prescription or the pharmacy needs something different. I know she is overworked, but I really don’t need to listen to her b****ching about the extra work and time spent on the phone. When I say I am spending hours on my phone myself with this[edit]p, I don’t even think she even hears me. Our healthcare system is such a freakin’ mess, it’s really sad.
    I finally got my prescription filled today after spending over 3 hours on the phone.

  7. Just heard of this at 7:44 am

    For the QL – quantity limit – you can ask your doctor to split the script. For example, if the insurance company pays for 2 pills a day, get those filled on the insurance. Then use cash (with a free online discount service such as Goodrx.com — which has discounted me literally hundreds of dollars off the retail cash price using a discount code, no sign up, nothing, just punch in your medicine strength, quantity, name, etc and get the price and code at various participating national retailers. My pharmacist recommended to me).
    It is often Cheaper to simply use the discount code than it is to pay a copay, so crosscheck both to see which is best.

  8. Rita KIMBEL at 5:40 am

    Dealing with PA for the last 12 months, detoxing too many times. It’s ridiculous, I’m so fed up with this, how the h-ll did we get to this point.

  9. Tim Mason at 2:00 pm

    I am on short term disability. I struggle to sleep at night. Usually 2 hours asleep and 30 minutes up. Lots of Unisom and melatonin. Two of my doctors, 1 the neurosurgeon and 1 the pain management doctor said I would never recover from this FBS. I had scar tissue surrounding the nerve roots and epidural fibrosis what ever that is.
    However, the last MRI showed an extruded L4 disc causing central canal stenosis but no one in town is willing to fix it. I think this is where all my pain and lack of mobility is coming from. (legs feel like they are in a vice at night) This is truly a death sentence.
    I have reached out to Emory in Atlanta and they are going to review my images.
    With the current lack of supply of break thru medications I find myself running the three different pharmacies in the Walgreens circuit. The patch I am on is non formulary (37.5ug/hr) made by Mylan and I know if my Social Security goes thru I will not get that dose. I do not want to go any higher on this medication because it is 50 to 100 times stronger than morphine. The pain is excruciating without medication. There is a video on FB – Arachnoiditis that demonstrates what I am going thru. FB Arachnoiditis SCS. Watch that film of the lady in Canada and everyone will see what we are going thru being denied our medication. It is cruel and abusive to treat people like this.

  10. Tim Mason at 9:42 am

    Deborah Fochler that’s what we have is a “For Profit” system.
    For example: A dental implant in Socialized Medicine costs 300 dollars. The same tooth in the US is $4000 dollars.
    Dental suppliers are going around trying to increase US Dental profits by offering carbon fiber posts for implant allowing the dentist to increase his or her profit margin.
    A small plastic sheath for use on IV tubing cost a middle man $10/100. The middle man repackages it and sells it for $10 each. The Hospital charges you or your insurance company $100+ each.
    Its called Capitalism.
    As far as drugs go, if a company comes out with a new drug they try and recoup all of their research efforts for synthesis, testing of all sorts, patent filings and pass these costs on to the sick person.
    Finally, when the patent runs out and the drug sells for pennies a dose, they have something new, more expensive. and don’t forget pushing the off label use to sell more, more. This is what happened to Cymbalta and Gabapentin.
    I remember working for the company that made Viagra. The clinical trial was done on healthy college students so as not to kill someone with a bad heart. Low and behold the clinical trial subjects reported an amazing ability to copulate 24/7. Bam….of label use better than what it was designed for. When we reached our millionth dose sold we got a bonus and if we got an Rx for Viagra it was free.

  11. Cindy J Deim at 7:41 pm

    I just wanted to remind people about Opioid Policy Steering Committee: Prescribing Intervention-Exploring a Strategy for Implementation; Public Hearing; Request for Commentshttps://www.federalregister.gov/documents/2017/12/13/2017-26785/opioid-policy-steering-committee-prescribing-intervention-exploring-a-strategy-for-implementation#p-4
    Please write them and tell them your story. It’s important to us all.
    Each state is also doing it as well. I’m in coloradohttps://www.colorado.gov/pacific/dora/Medical_News
    The state one has to be in by the 1/17.
    this is one of those things that everyone can do to help with pain medication. We all wonder what we can do, this is a big one.

  12. Sher at 7:34 pm

    Thank you Mr. Ariens! This is very valuable information. I also would like to say thank you for your advocacy, it’s so appreciated. As a chronic pain patient I feel rather hopeless & frustrated most of the time but for all who fight for us, it means more than you can imagine.

  13. Cindy Raisor Mears at 6:51 pm

    I am deeply appreciative for this well written, informative, contemporary article.

  14. Tim Mason at 10:37 am

    Terry. Check on Caremark. Walgreens takes Caremark even if CVS is on the Card. Many people think they have to use CVS when they don’t.

  15. Matthew J. Smith at 9:25 am

    Thanks Steve, I want this over ONCE AND FOR ALL, I went through this 4 times last year & had Rxs I couldn’t afford (on my own) to fill, so I turned them back in, causing tapering , by me, and ultimately wothdraw, which is easy compared to the return of the NEUROPATHIC PAIN OF IATROGENIC, ADHESIVE ARACHNOIDITIS !! I got hit again 2 weeks ago and am going to take up the fight that my Doctor (& his employees have been fighting up to THIS point)… I have had ENOUGH, I have been advocating online, through social media, for this GENOCIDE of CPPs to end, but now have , here, a road map to advocate for myself now and I can be a real PAIN IN THEIR A$$ !!… Again, THANK YOU FOR THIS invaluable instruction !! EVERYONE RAISE YOUR VOICE, we are many and can be heard if we fight this together – SHAME THE CDC, the GDA, POLITICIANS , the AARP, the AMA, & DOCTORS for allowing us to be TORTURED !!

  16. Dena Meeks at 4:15 am

    I cried as I read the response from Winnie McDavid, my story is so similar except that I never made it back to work and my debts to pay for medical expenses did lead to bankruptcy and we lost our home. Now we pay over $700 per month for my insurance coverage on my husband’s employer’s health insurance and this week I’m forced to use Good RX coupons to be able to afford my much needed ER RX plus my IR RX used for ‘break through pain’ which is a 24/7 issue, so another $200 per month where last year it was $20 per month. Now I have to start fighting via their appeals process and worry about the stress and what else could go wrong. I wish none of us were facing these horrific daily battles but it helps to read these other stories and realize that I am not alone.

  17. Winnie McDavid at 8:44 pm

    Thank you Steve for educating those of us currently going thru the PA & insurance denials & potential others who have yet to experience such a debacle. I am a therapist who has lived 30 years in chronic pain. I left my career in 2003 & went on SSD, & having been placed on extended release pain meds, my pain was under such good control I was able to obtain another degree & also return to my PT career. A patient once said “ya gotta keep old Arthur moving,” referring to arthritis. I came off of SSD & my pain meds were covered 7 years under company insurance & all was well until one year ago. Suddenly they asked for PA. My rheumatologist had to send records showing why I need ER OxyContin. It took 2 months for them to tell me the real problem: he was not a pain specialist. I change doctors. PA asks proof & wants pain mgt agreement, tx plan, etc. Then they say the Dr didn’t send anything, Denials ensued for 4 months. New Dr terminates me-went to another pain clinic & again the PAs denied, paperwork lost etc. Under this ERISA self funded system there were only 2 appeals – 1st automatically denied, 2nd appeal in September approved meds for next 6 months & did not address the gist of my grievance- by then I was 4K in credit card debt, buying the meds so I could continue working. They asked for receipts then closed my case with no further explanation. 12/27 I consulted an attorney who advised to file complaint with Insurance Commission. At this point I’m informed of my right for a 3rd party review. Last week I contacted ins co & requested such, & by next morning they approved to cover all but one month last year. Of course I’m elated, but the QL yet increase in fibromyalgia pain, time loss from work, $100 a month in interest, now having to change jobs (if anyone will hire 66 year old in chronic pain)-the incalculable stress from facing bankruptcy- cannot be fixed. THIS DISCOURSE is a brief overview of what I endured. My original rheumatologist could be forced into retirement- he truly cared. Now I suffer in pain & y’all know how the domino effect works: increased pain leads to less sleep leads to weight gain leads to other health conditions. BUT knowing there are people out there fighting for us gives HOPE.

  18. Ellen at 5:00 pm

    You are absolutely correct they try wear you down first with phone tree then appeals
    What about patients right to legitimate treatment and for many chronic pain patients opiates do work These committees, CDC upcoming opioid conference in Atlanta is packed with cherry picked “experts” who are more like addiction then pain doctors No panel of chronic pain patients who benefit from responsible doctors and patients are invited to speak The good pain doctors because there are few can’t get away and these guideles federal 100mg MME Washington state wants less 90 mg MME every state different Alcohol Ritalin (again not true patients with dx. ADD) adderall sold and sorry for some loved ones who did loose person to OD most cases meds were stolen not RX to them they die committing a felony yet legitimate patients in pain are punished And long acting are better for continuous pain to prevent up and down control but again people illegally obtain them crush and snort med so again chronic pain patients get punishment
    Why should I have risk dangers of a spinal pump because you can give such a low dose but in a dangerous place and won’t solve my arm and neck dystonia or headaches induced by levodopa in fact can cause headaches/spinal
    I thought if we went to pain doctor we could keep what been on for years but at least WA state doctors are being scared somehow One side says if 2 doctors agree or legacy patient you did not need meds cut back but that is not what is happening. I told my kids if I get it so much pain I commit suicide then they should sue for wrongful death
    All any chronic pain patient that jumps through hoops is quality life not zero pain but not there cut back doses I am scared everyday and for last few years I did not worry now I do every minute everyday

  19. Terry at 2:19 pm

    That was a good article but it still leaves me terrified that my scripts are going to be cut. It sounds like between the doc and the pharmacy I could be going through horrible withdrawals, I don’t know what it feels like but it sounds awful. Is there any way for me to take their power away and get my prescriptions filled as written? It sounds like the process, even if successful could take two weeks. I’ve been taking the same stuff for 10 years and now my prescription insurance, Caremark, says that we are only allowed to get prescriptions from CVS, that sounds like a monopoly, I’ve written my congressman and senators but nobody wants to be on the “wrong ” side of things so nobody will help us. I wish there was something that I could do to prevent all of this before it happens. Can I sue my doc for building up my tolerance and than then cutting my prescriptions? Can I sue Caremark or CVS if they force me into withdrawals for absolutely no reason, none that I was the cause of, I always passed the urine tests, I never run out early and I take my medications exactly as prescribed. It’s starting to feel like a dictatorship not a democracy.

  20. Bob Schubring at 1:06 pm

    In my reading of the Complaint in Washington v Sessions, Mr Washington and the other plaintiffs are suing Mr Sessions for allowing DEA to practice medicine without a license. The claim, which is Count 5 of the Complaint, is that in 1974 when Congress created the DEA, Congress temporarily put some example drugs on Schedules I, II, and III. Congress ordered DEA to consult the Surgeon General and have tests done and hearings held, to rule on what drugs actually belonged on which of the Schedules. After 44 years of delays, DEA has still not complied with that law and is still practicing medicine without a license.

    Apparently 50 States became so dependent on grants of DEA drug war money, that they failed to enforce state laws prohibiting the unauthorized practice of medicine. The present perverse incentives Steve describes, in which an insurance company can force people not to use benefits that they paid the insurance company for, is driven by this corrupt system of selective enforcement of laws.

    On February 14th in US District Court in New York City, the Washington v Sessions hearing is held. Almost certainly this matter will wind up in the Supreme Court, no matter what the trial judge rules.

  21. D. Garrand at 1:01 pm

    This exact thing happened to me when I attempted to fill my extended release pain medication this month. Why must it be such an ordeal for pain patients to get treated fairly? I realize there are people out there who abuse these medications but true chronic pain sufferers shouldn’t be punished for the stupidity of those people. I’ve been 100% disabled and on these medications for many years. I have been using the same pharmacy for all of my medications for at least 10 years, I’ve been with the same pain management doctor for more than 8 years and I’ve been with the same insurance company (Humana) for more than 5 years. I’ve had 15 surgeries in the past 14 years. I get regular procedures for the pain, including a failed implanted nerve stimulator that almost killed me due to a massive infection, radial frequency ablations, epidurals, and facet joint injections. If it weren’t for my pain medications I wouldn’t be able to get out of bed. I hate the fact that I have to take these medications. I hate the looks and whispers from pharmacists and techs who are new and not familiar with my situation (and even some of the ones that aren’t new yet don’t understand). I wouldn’t wish this life on my worst enemy. Sorry for the rant. It’s just so disheartening when you do your best to follow the rules to a tee only to find out it’s still not good enough.

  22. Patricia Davidson at 12:41 pm

    Thank you Steve! I’m fighting Medicare as I type. I have a pre auth for my pain medicine but was told this month that my Dr needs to do another pre auth because MME is higher than CDC guidelines. My Dr faxed paperwork right away but insurance company denies getting it. They also claim the Dr NEEDS to complete paperwork within 24 hours of recieving it. I have been getting the run around for 6 days. I put the medication on a credit card and my pharmacy will be happy to reimburse me. After reading your article It looks like I might need to fight like a dog with a bone to get this medicine paid for. If I don’t I’m out nearly $1500! My BP has been super high from all this stress and I can’t keep getting the runaround as it’s making me sicker! Thx for the helpful info. I hope I’m successful

  23. Deborah Fochler at 12:01 pm

    Thank you for the information. Last year before I had medicare, I had a horrible experience with my insurance company, surprisingly not over pain medications but over a new chemotherapy drug. My physician was using it “off label” which means for a condition it was not originally approved for. But she thought it was one of the only drugs which could help me. She asked a few other doctors and all agreed. The drug was very expensive, over $4000 for the medication and another several thousand for the cost of infusion. She was able to get the drug company to cover part of the cost for the drug for me. She filed with my insurance and they declined it. She asked for a peer to peer review. Spent a lot of time making sure she had all information correct. The physician she spoke to – agreed with her that I needed the drug. She called me so happy. The next day, I get two letters from my insurance company. One saying that the peer to peer review was in agreement with my doctor. The next letter saying they were cancelling my insurance as of the fifth of that month. The real kicker was I paid my insurance on the 1st ($1800) and they did not return it.

  24. Andrea Edwards at 11:27 am

    Thank you so much for this useful information. I am a chronic pain sufferer and have been for three years. I report to my pain management doctor every 30 days because they have changed their policies and will no longer give me a prescription for more than 30 days without seeing me. I believe it’s another way to make more money. The doctor never touches me and usually nothing has changed I just need a refill on my pain medicine to help me function.
    I’ve been subjected to random drug testing and I’ve heard about patients been cut off cold turkey because of medical marijuana. I am a little concerned because I took one hit off of a CBD oil device to see if it would help me with my chronic pain. Is this something that would show up on a drug test since it’s not the stuff that makes you “high “and is supposed to be just for the pain?
    Also any helpful advice on speaking with my pain management doctor about all this would be much appreciated.
    He seems to act like he’s on my side when I’m at my visit, knows that I’m a legit patient not seeking drugs to get high.
    I have never missed an appointment never failed a drug test it’s just disgusting what they’re making these chronic pain patients go through to get their medicine. I’m very concerned and worried about this and do not understand why they even include chronic pain managing patients on opieds in with heroin overdoses.
    Hope and praying that this gets better for us.

  25. Cynthia Thompson at 10:21 am

    My part D plan was making a lot of money on the many opiates I was prescribed over the last 17 yrs, but after everything that’s happened due to the new RECCOMENDATIONS from the CDC, I was prescribed Subutext & after 4 months it is still waiting on a prior approval? This entire narrative is INSANITY if you are a true CPP! If I a hospital denies a terminally ill little girl pain relief, we don’t stand a chance! Get on your phones or computer and send as many e-mails or calls to your State, Coubty, Local & Federal government health agencies & elected officials!!! Our voices deserve to be heard as well as our loved ones! #I HAVE A VOICE

  26. Nana at 9:38 am

    Thank you Steve.

    I have experienced this with Lidocaine patches!

    You cannot overdose on these… What? Do they think you will squeeze them out and drink them?

    (When this first happened ExpressScripts said late last year that soon ALL pain relief meds would be prior authorization. War on pain patients!)

    Addictive? No. They are just expensive.

  27. Jill at 8:44 am

    Thanks Steve. My plan paid so little on my pain meds when they decided they needed pre-approval, I decided to go with GoodRx and am getting a cheaper price. Hope this works for a while. Cannot function without these meds!!

  28. taylo138 at 8:37 am

    Thank you for sharing this information.
    I need it right now!
    I have a prescription that was given a PA good through 5/13/18.
    Went fill it on 1/13, out of stock and sent to another Pharmacy.
    These were my options:
    1. Get 90 not 120 tablets. Pay $800+ for 90 tablets that would be applied towards our yearly out-of-Pocket maximum.
    (Unless we get have a PA for 120 tablets…which we have but mysterious disappeared.
    Or,
    2. Apply a coupon card, get 120 tablets for $800+ but that money will not apply towards our yearly out-of-Pocket maximum and I cannot use money in a healthcare savings plan.
    Or,
    3. Talk to my doctor about the above insanity!
    *After taking a long nap to relieve a stress headache, I looked up the medication and found 2-different PA codes. I’m going to ask the Pharmacy to run both codes and see what happens.
    I’ve stretched the last few tablets out over the past week and will have 1 tablet left tomorrow, when I meet with the prescribing doctor.
    I’m exhausted from trying to get one prescription filled.
    Also, I just went through the PA process on 1/4 for a different medication.
    I’ll copy the information you posted.
    Thank you for giving me a road map!

  29. Daisy Robles at 7:36 am

    Thank you! The steps to take are so appreciative! The right wording is appreciated!

  30. Kris Aaron at 6:28 am

    Thank you, Steve! Once again, for-profit health care is showing us their true colors (same as our currency). Don’t let them get away with screwing us — make NOISE! Cost them time and money! RESIST!!

  31. Tim Mason at 6:15 am

    It’s always something else these days. People are already frustrated with poor health and limited capability with pain and they add another frustration.
    I for one am tired of taking medication as I guess most people are.
    My circuits have become “overloaded” with questions from providers, denials, third party billing fiascos and the list goes on.
    The wounded are having to stand up and fight. It should not be this way.
    I think it was Eddie Arnold that got it right in his song. “Make the World Go Away”, and when Clint Eastwood in Outlaw Jose Wales said: “Dying is easy, its living that’s hard”.

  32. JoDawn at 6:15 am

    Thank you so much!! This will be of HUGE help to anyone that comes across this problem! I especially appreciate your tips, like telling them ahead of time that continued appeals will be forthcoming and the specific wording that is needed, such as mentioning “practicing medicine without a license “ and our right to have things expedited! I did NOT know that!

    Again, thank you for your (now bookmarked) very helpful article!

  33. Dena Meeks at 4:02 am

    I am so thankful for this detailed guide because my insurance company is doing this to me right now, cutting quantity limits to zero on my extended release pain medication. My husband carries me on his employer’s health plan and the letter from the PBM arrived just before Christmas and offered no alternative covered medications. Today I will be filling my prescription via a ‘Good RX’ discount coupon because I knew I could not just stop taking these medications after 10+ years and I certainly plan to appeal since no clinical data was received, just a board room decision. From my previous career as an HMO Underwriter, I also recall that filing a complaint with your state Department of Insurance (DOI) is another way to get the attention of your insurance company because they have to report the number of DOI complaints on quarterly and annual financial reports to the State. We always worked hard to avoid DOI complaints, amazing how quickly something is once again covered. It’s also a sad fact that the insurance companies hope people will give up if enough obstacles are put in their path through the appeals process, so don’t give up, put as much information in writing and keep copies of everything, including names and dates of phone conversations because those ‘recorded lines’ never seem to exist to help the patients. Sadly, “patience” is what we need as chronic pain patients and it can be hard to find when you are fighting with people who don’t care about your illness, pain or quality of life. Thanks again to the author for the very useful information, we can use all the help we can get.

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