CPP: A payor, usually the patient's prescription insurance, requires prior auth for a medication that is not typically listed on their formulary. The provider, usually the prescriber, must make a case to the payor, pleading their case that the patient needs this medication. The prescriber will indicate failure of previous, step-therapy treatments or allergies, or other reasons as they plead their case.
CP: And if the provider does all this?
CPP: The payor, in this case the insurance, can choose to cover it or deny the claim.
CP: And if they approve it?
CPP: Then the prescription should be covered but still may incur a large copay. It could be a normal copay, but this is often not always the case. Why the lesson today, CP?
CP: Oh, just making sure it hasn't changed in the last week on me.
CPP: I feel a story is imminent. Do share.
CP: Hello Dr. Zoffis!
DZ: Hello!
CP: I was calling about a p/a for our mutual patient. I see you faxed us a novella regarding the p/a.
DZ: I did.
CP: It's still not covered and when I called Cover My Meds, they said you deleted the request.
DZ: I deleted this one because we already did one in November and it was approved for a year; which is what we faxed you.
CP: Curiouser and curiouser. I shall call them, armed with this fax from you.
Stupid Ass Insurance Department Now Obfuscating: How may I frustrate your life today?
CP: I was calling about a p/a that was approved in November that I, for some soon-to-be-explained reason, cannot get to go through.
SAID NO: Let me check. Which drug?
CP: The patient had it approved while they were still using Causes Virgin Suicides as their pharmacy, but transferred to us the beginning of the year.
SAID NO: Ah yes. I see they have 4 NDC's for this.
CP: They don't.
SAID NO: Well my system shows 4 are available.
CP: Can you order them through your fancy system?
SAID NO: No.
CP: Then they are NOT, in fact, available. I have all 3 of my suppliers pulled up and there is exactly one NDC, brand only, available for this product. Which, may I ask, is covered?
SAID NO: None of them.
CP: Ok. But I have an approved p/a. For which NDC was it approved?
SAID NO: The one you are billing.
CP: Yet here we sit, you telling me the drug is not covered.
SAID NO: Yes.
CP: And I have an approved p/a, complete with approval number and date of approval.
SAID NO: Yes. But it's not covered.
CP: Explain.
SAID NO: This drug is not covered so the p/a should never have been approved.
CP: Yet it was. I am going to need you to fax that information to the DZ. They would never believe me and I'm going to get yelled at.
SAID NO: Done.
CP: Thanks.
CP: Hey, DZ. You're never going to believe this. <recounts story>
DZ: Damn. That's epic. I guess I'll contact them and figure out how to get it covered.
CP: <does double-take> It's. Not. Covered. Period. Good luck in your endeavour!
*side note: as I was listening to SAID NO explain this to me, Unbelievable by EMF was playing on my XM
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