Prescriptions requiring Prior Authorization

[Estrace]

For retail pharmacists, do you cash out prescriptions requiring PA, sell to the patient and then have them come back for a refund when PA is approved?

---

Members don't see this ad.

 

[Wheresmyaricept]

No, because if the prior auth was approved for a start date later than the original date of service of the sold rx, it still won't adjudicate. And I don't like to delete sold prescriptions and rebill for a new date of service because that's fraud.

 

[Rouelle]

You also run the risk that the PA is denied

 

[pezdispenser]

No way. The chances are too high that the doctor may change the drug, or not get the PA approved.

But if you really want the patient to start the drug right away, there are sometimes manufacturer's coupons for the first month from drug reps or e-mail lists like e-Pharm/alert: http://www.alertmarketing.com/Programs/PharmAlert_eMail.aspx . Of course, you will still run into the same problem the next month if you don't follow up with the PA.

 

[PharmdA07]

For PA with me: if I know the doctors well (of which several I do in my current retail practice) and if I have time (which is not easy to accomplish at the present due to the cold/flu season), I will talk to the patient first and then call MD to discuss alternatives (as in if Dexilant requires PA and the patient hasn't tried any PPI yet, I will try billing for Nexium/Protonix and then discuss with MD; same thing with Livalo vs.Crestor/Lipitor --this I will look for P450 interaction first on their profile though; same thing with the bisphophonates or the benzo; same thing with antibiotics--I will try to find a covered drug with the same bug coverage or at least same indication and go from there). Of course, this takes time and sometimes A LOT of time with all the calls and talking I have to do, that's why I only do it when the situation allows (and frankly, only for nice patients LOL). I also try to split combo drugs such lotrel into its individual components (which will be covered by insurance) or change between forms like Toprol XL vs Lopressor etc...

PA, to me, is just a way for the PBM to save money. I think it's really sad to say so. To my understanding with insurance regulation, just like
Wheresmyaricept said, it's fraudulent if you refund and try to rebill when PA approval date is later than the date Rx is dispensed. Besides, MD may fax back a message to you requiring a change to a different drug which is completely different than what you gave the patient.

There is a service called covermymeds.com where you can help as the pharmacy side to expedite the process. I did this several times for my chemo patients requiring Emend or mucositis treatment. Again, this takes time but to me, if the patients are medically in need of a clinically sound drug (in my pharmacist's consideration) and they are at least NICE to me, I will do whatever it takes to help them get the drugs. If these people are nasty and demanding to me, sorry but you can wait or go to the ER/ urgent care centers and they can administer the drug for you or you can try a different pharmacy down the street!

 

[BenJammin]

Just wait until you deal with a doctor who doesn't do PAs. Our outpatient clinic got dealt a blow by a nearby doc who refused to do a PA on the Eliquis he prescribed. Tried to see if he would change to warfarin (covered by pt's insurance) and he said "no. tell them to pay cash for it or no drug".

Well, okay.

 

[Estrace]

Well, my rmx will reprocess them and then call patients to come get refunds. We have leaflets still waiting to be refunded since last year and the patients never came. I don't think this is right.

 

[PharFromNormal]

Well, my rmx will reprocess them and then call patients to come get refunds. We have leaflets still waiting to be refunded since last year and the patients never came. I don't think this is right.

If the PA was authorized to start on the date of dispensing it's fine. If they never come to pick up their refund it should technically be backed out of the third party within whatever terms you have with the third party (I.e 14-28 days). By collecting more than the copay (cash or U&C) and billing the insurance you could get into hot water.

I suggest notifying the customer that they can come for a refund but keeping it processed as a cash Rx until they actually show up for their refund.

 

[zelman]

pri·or1
ˈprī(ə)r/
adjective

1. 1.
   existing or coming before in time, order, or importance.
   "he has a prior engagement this evening"
   synonyms: earlier, previous, preceding, foregoing, antecedent, advance;
   formalanterior
   "by prior arrangement"

 

[CynicalIntern]

Well, my rmx will reprocess them and then call patients to come get refunds. We have leaflets still waiting to be refunded since last year and the patients never came. I don't think this is right.

Yeah, that's super-illegal because you're overbilling. Charging the patient the cash price AND billing the insurance is making fraudulent claims.

 

[farmadiazepine]

Don't cash out PA's and expect them to go through at a later date. The only times I cash out a PA and sell it is when the customer clearly understands that they won't be getting their money back at all. If it goes through, great, then we'll call them and refund them the difference, but if it doesn't go through, that's that. It was their choice to pay. If you let a customer believe a PA will go through, and go ahead pay for it now, you'll get a refund later, you are totally misleading them, and they are going to feel cheated.

 

[MountainPharmD]

Just wait until you deal with a doctor who doesn't do PAs. Our outpatient clinic got dealt a blow by a nearby doc who refused to do a PA on the Eliquis he prescribed. Tried to see if he would change to warfarin (covered by pt's insurance) and he said "no. tell them to pay cash for it or no drug".

Well, okay.

I have a group of doctors who do the same thing. I know the PA process sucks but refusing to do them is a little extreme.

 

[Ackj]

Typically the rx that require PA aren't reasonably affordable to pay cash, so it doesn't come up all that often. The discussion is usually "You can wait for approval, call your doctor for another drug, or pay $400 and get this today." I have had a patient who was okay doing it for Zyvox, since that really couldn't wait. We have a huge list of PAs that never get approved, so I really wouldn't recommend doing it often, if at all. Definitely don't be the guy who says "I'll just give you 2-3 pills until it's approved..."

We will do it for a few patients with a weird Workers Comp group that wants a PA on every single rx, and you have to call up their help desk which is only open 8-4 M-F. For those, it's usually ibuprofen and hydrocodone, which is cheap enough to cash out and rebill later.

 

[Sparda29]

There are some docs that we deal with who just fax us the PA form (signed by the doc) along with a copy of the patients chart. We fill it out and send it back to insurance, approved most of the time. Or we know that there's not enough info in the chart to get the PA approved, we just lie about it and write what we have to write to get it approved.

 

[Estrace]

Typically the rx that require PA aren't reasonably affordable to pay cash, so it doesn't come up all that often. The discussion is usually "You can wait for approval, call your doctor for another drug, or pay $400 and get this today." I have had a patient who was okay doing it for Zyvox, since that really couldn't wait. We have a huge list of PAs that never get approved, so I really wouldn't recommend doing it often, if at all. Definitely don't be the guy who says "I'll just give you 2-3 pills until it's approved..."

We will do it for a few patients with a weird Workers Comp group that wants a PA on every single rx, and you have to call up their help desk which is only open 8-4 M-F. For those, it's usually ibuprofen and hydrocodone, which is cheap enough to cash out and rebill later.

Even for the cheap stuff, are you allowed to rebill later if the approval date is different from the original date the medication was dispensed? Just like someone said above, PA means you have to wait for approval before dispensing.

 

[PharFromNormal]

Everyone is aware that there are instances in which a prescriber can get a retro start date on a PA right?

If you can clearly and simply articulate this and a patient fully understands the risk they take when they pick up a cashed out PA, I have no problem.

If they brush me off as "hurr durr my doctor will definitely approve it" while I'm trying to explain the caveat of the start date of the PA vs the dispensed date then I don't bother.

As long as you never change the dispensed date on a cashed out, picked up PA script you should be fine.

 

[trailerpark]

Am I the only one who faxes a copy of the rx with "needs PA, the ID number and phone number" then be done with it. After that we let the patient knows it's in the doctors hands and to contact the dr office with any follow up. And we let them know it can take well over a week or two.

 

[zelman]

Even for the cheap stuff, are you allowed to rebill later if the approval date is different from the original date the medication was dispensed? Just like someone said above, PA means you have to wait for approval before dispensing.

Jesus Christ. I put the definition of the word "prior" 6 posts up. Why do people think the word "authorization" negates it completely?

 

[Estrace]

Jesus Christ. I put the definition of the word "prior" 6 posts up. Why do people think the word "authorization" negates it completely?

What are you talking about? I was agreeing with you. What I normally do is exactly what trailerpark stated above.

 

[PharFromNormal]

Jesus Christ. I put the definition of the word "prior" 6 posts up. Why do people think the word "authorization" negates it completely?

Jesus Christ. You realize prescribers can actually complete this process AFTER the date of dispensing to get RETROACTIVE approval status starting before the date of dispensing. Using the definition of prior is a little misleading when discussing authorization ACTIONS vs authorization STATUS.

 

[Wheresmyaricept]

Jesus Christ. I put the definition of the word "prior" 6 posts up. Why do people think the word "authorization" negates it completely?

You know that a PA can be retroactively dated right? That's why I used very specific wording in my first post like "if the start date is approved later than the dispense date" meaning that the start date can be set to a date prior to the prescription being picked up. Don't get sassy with people when you don't understand something.

On a different note, I can easily foresee with all the deductibles going up, someone paying cash and then getting the PA approved and it processes for the same price because they have an $8000 deductible.

 

[zelman]

Jesus Christ. You realize prescribers can actually complete this process AFTER the date of dispensing to get RETROACTIVE approval status starting before the date of dispensing. Using the definition of prior is a little misleading when discussing authorization ACTIONS vs authorization STATUS.

If you hold a gun to the head of your PBM's CEO you can get your copay lowered and off-formulary drugs covered. That's not "prior authorization", it's an administrative approval and should never be expected to occur. I'm citing the actual process and you're talking about authorized deviation from the process.

 

[zelman]

What are you talking about? I was agreeing with you. What I normally do is exactly what trailerpark stated above.

Sorry. You posed a question and didn't explicitly answer it, so I misread your intent. My bad.

 

[npage148]

Am I the only one who faxes a copy of the rx with "needs PA, the ID number and phone number" then be done with it. After that we let the patient knows it's in the doctors hands and to contact the dr office with any follow up. And we let them know it can take well over a week or two.

That's how we do it esp since we deal with 3 or so large low cost clinics that will never do a pa (not out spite, just laziness/over worked)

 

[genesis09]

I don't get why providers act so surprised when a new and expensive drug requires a PA. I sometimes use covermymeds.com to get the PA forms. Most of them are one page.

 

[farmadiazepine]

PA's can be retroactively dated. The problem is when you tell a doctor's office to retroactively date it, and when they get an approval, they don't even remember to ask for it to be approved on an earlier date. To call an office back and have them redo all that stuff is a hassle. Of course, it should have been done right from the beginning, but remember who we are talking to: secretaries, nurses, assistants, and people who barely passed high school or have a GED.

Are you sure the doctor wants the patient on Lantus, Levemir, Humalog, and Humalog Mix? --Yes.

 

[PharFromNormal]

If you hold a gun to the head of your PBM's CEO you can get your copay lowered and off-formulary drugs covered. That's not "prior authorization", it's an administrative approval and should never be expected to occur. I'm citing the actual process and you're talking about authorized deviation from the process.

Lol you are so misinformed.

 

[WVUPharm2007]

I type PR and fax it to the physician. It is his problem. Unless that bitch says Print Ready, we're done here.