Christopher Marks noticed an immediate improvement when his doctor prescribed him the Type 2 diabetes medication Mounjaro last year. The 40-year-old truck driver from Kansas City, Missouri, said his average blood sugar reading decreased significantly and that keeping it within target range took less insulin than before.
But when his doctor followed the typical prescribing pattern and increased his dose of Mounjaro — a drug with a wholesale list price of more than $1,000 a month — Marks’ health insurer declined to pay for it.
kffhealthnews.org
Medicare has tried to get ahead of this by putting out a statement to plans in December saying they are not allowed to use Prior Authorizations as a road block. They can require a PA but it’s only suppose to allow them time to determine if the med is appropriate and necessary. It doesn’t say that they have to approve all PAs.
I ran into PA for the first time in January when Wellcare tagged a client who was denied a temazepam refill pending prior authorization. This is a med she has taken for years and never a problem with her prior PDP.
Fortunately for her, temazepam is generic and she could get it cheaper with GoodRx and bypass the PA requirement.
But when his doctor followed the typical prescribing pattern and increased his dose of Mounjaro — a drug with a wholesale list price of more than $1,000 a month — Marks’ health insurer declined to pay for it.
States Target Health Insurers’ ‘Prior Authorization’ Red Tape - KFF Health News
Doctors, patients, and hospitals have railed for years about the prior authorization processes that health insurers use to decide whether they’ll pay for patients’ drugs or medical procedures. The Biden administration announced a crackdown in January, but some state lawmakers are looking to go...
kffhealthnews.org
Medicare has tried to get ahead of this by putting out a statement to plans in December saying they are not allowed to use Prior Authorizations as a road block. They can require a PA but it’s only suppose to allow them time to determine if the med is appropriate and necessary. It doesn’t say that they have to approve all PAs.
I ran into PA for the first time in January when Wellcare tagged a client who was denied a temazepam refill pending prior authorization. This is a med she has taken for years and never a problem with her prior PDP.
Fortunately for her, temazepam is generic and she could get it cheaper with GoodRx and bypass the PA requirement.
