ObamaCare: Walmart can't fill perscription until doctor talks to insurace company !??!!??!

it's called step therapy.. even though she has been on these drugs for six years whatever prescription plan she has could have changed their procedures to see if something cheap will work for her. Even if she has tried step therapy before they may try it again in later years unless the doctor can give a reason why she needs the more expensive drug. Step therapy has been around a long time, sorry but nothing new.

reply to post by Chrisfishenstein


Well, I often agree with your points as well..but we're worlds apart here.

The issue isn't whether your points have merit, and I should be clear about that. 10 years ago I was a rather vocal defender of benefit reform and cuts to weed out the fraud. That was 10 years ago in a nation much different than we have today for the daily level of suffering both in financial and emotional costs. Now? We have unemployment raging, 1/3rd of the nation on Food Stamps and climbing steadily while the only thing steadily climbing is debt ...both National and Personal.

Reform is needed and when the suffering has been stabilized to anything remotely like a figure showing decline in that pain? I'd again all for reforms to drop the abuse and fraud.

Right now though? We have a nation where real people are really hurting REALLY badly. This is the worst time in history to think about any cutting that impacts individual people in need in negative ways. Now, if all else which could be cut with many more zeros than this, already HAD been and these areas were all that remained with fat and fraud? We'd have a different discussion, to be sure ....but where people seem to want to START the cutting with all else considered is what I find almost barbaric in the lack of empathy for the individuals it hits.

reply to post by Chrisfishenstein


No it isn't. All insurance companies require prior authorizations. Medicaid and Medicare may require them more but it is not wholly exclusive to them.

Originally posted by Xcalibur254
reply to post by Chrisfishenstein

 

No it isn't. All insurance companies require prior authorizations. Medicaid and Medicare may require them more but it is not wholly exclusive to them.

Prior auths for Prescriptions? I've only seen those on really expensive drugs or brand name meds, but it's not as common as you seem to think, even with Medicare.

It really depends on what insurance you have, most major insurance providers only require PA on stuff like Atripla (if they'll even cover it) or some antibiotics. Some of the smaller insurance companies will want PAs on more common medications, but that's rare. Even with Obamacare there hasn't been too much of a change in the processing of prescriptions.

OP, idk who your experience is with but you might want to switch insurance providers or pharmacies.

reply to post by RocksFromSpace


Yes this is true, my husband and I have government insurance because he is retired from the military, since Obamacare came to be we are required to submit a reason why we need non generic medications, something that I find very outrageous when our insurance just double since October and our deductibles triple.

If we are paying more why we can not get what we want.

That is my question.

Obamacare is turning the working class that can be mandated into nothing but a big Medicaid population with his crappy insurance that will only benefit the insurance companies pockets.

Beware because this is just the beginning. Sadly I am one of those people within the 3% that can not take most generic drugs due to side effects.

Originally posted by beezzer

Originally posted by RocksFromSpace
to see if they are really needed and/or a cheaper alternative can be prescribed.

To see if they are really needed? Really? WTH!

Obamacare. Why not just kill everyone that needs medicine, THEN it'd be affordable!
(no disrespect to your mother)

edit on 12-7-2013 by beezzer because: (no reason given)

Except this has nothing to do with Obamacare. Unless it was in effect 7 years ago when the same thing happened to me.

CJ

reply to post by ColoradoJens


We have been under Humana with the government since the 90s, but it wasn't until last year that our prescriptions were questioned.

So for my husband and I is not 7 years ago, is last year when Obamacare took over new contracts from Humana in October.

reply to post by RocksFromSpace


Insurance companies have been doing this forever. Anything to give their shareholders more money.

I have no clue why you think this has anything to do with Obamacare. You must have no experience dealing with a for-profit medical system.

reply to post by ArrowsNV


I agree it's not all that common. I may send one or two PAs a day. However it's more than just brand names and expensive drugs. I just had to do one on generic Ambien and the cardholder had either UHC or BCBS. In fact I find most of the PAs I have to send are for generic mental health drugs (trazodone and ADHD meds probably being the most prevalent) along with brand name acne creams. I will say something that annoyed me the other day is when Medicaid completely paid for a 60 strip Suboxone script without even requiring a PA.

reply to post by RocksFromSpace


It's called prior authorization and it has been going on since before Obama was elected, it has nothing to do with obamacare

Originally posted by marg6043
reply to post by ColoradoJens

 

We have been under Humana with the government since the 90s, but it wasn't until last year that our prescriptions were questioned.

So for my husband and I is not 7 years ago, is last year when Obamacare took over new contracts from Humana in October.

Oh. I guess when it happened for me it was under something else. Guess it is just the way it is and has been.

CJ

Long time lurker here, and I figured it would be a good idea to post on this to clear up some confusion. I am a pharmacist who has been practicing since 2009, and I believe what we are discussing here is called a Prior Authorization. This has been going on for some time and has nothing to do with ACA. An example would be if a patient gets a rx for say Crestor (which is not available in generic form yet, and very expensive) the insurance company will reject on my end (at the pharmacy billing end) and say they prefer to start with simvastatin, pravastatin or atorvastatin.

From here, I would faxed the Dr the rejection, at which point the Dr could request an override. It is not always approved. I have some patients on chronic pain meds, and they have to be authorized every quarter, some every year, and some even every month....it really sucks for these patients. The approval process is slow and can take a week or more. That is not a good thing for someone who has been taking strong pain meds to be without them for a week or more......

Will this practice increase as a result of the ACA??? Good question. My instincts say yes, but I cant say for sure.

reply to post by badgerprints


I used to work at a big box pharmacy, and hated it. Now I work at a little independent with an extremely loyal client base.....it is so much more rewarding

americans are seen as pill junkies the world over what makes your country so ill .

i have never taken a tablet that my doctor prescribed and i am still living most of those doctors are only fit to fill the shelves at walmart and are little more than drug dealers in real life my 2 cents

Originally posted by beezzer

Originally posted by RocksFromSpace
to see if they are really needed and/or a cheaper alternative can be prescribed.

To see if they are really needed? Really? WTH!

Obamacare. Why not just kill everyone that needs medicine, THEN it'd be affordable!
(no disrespect to your mother)

edit on 12-7-2013 by beezzer because: (no reason given)

This has nothing to do with the Affordable Care Act. When Social Security began covering prescriptions, (under Bush) the process was handed over to private, FOR PROFIT insurance companies. This has been going on for a while. It is inconvenient. And be forewarned they ask for new pre approval every six months.

reply to post by Chrisfishenstein

Went to Walmart yesterday to refill my mothers prescriptions, she has been on the same medicines for 6 years, was told that one prescription couldn't be filled until the doctor talks with the insurance company. I asked why and was told that all "High Dollar Cost" prescriptions are being flagged and the insurance companies want to talk to the doctor to see if they are really needed and/or a cheaper alternative can be prescribed. Pharmacist said this is happening a lot, insurance companies are trying to cut out the Higher Cost drugs... Thanks ##snipped##

Please show us where it says or even implies that this person doesn't have private insurance. How do you get that "your" money is going to pay for this person's prescription?

Originally posted by geobro
americans are seen as pill junkies the world over what makes your country so ill

.

i have never taken a tablet that my doctor prescribed and i am still living most of those doctors are only fit to fill the shelves at walmart and are little more than drug dealers in real life my 2 cents

The food pyramid that started Americans eating a dozen servings of bread, cereal, rice and pasta created two generations of overweight diabetics. Now 95% of our "food" is made from poisons and genetically modified things things that don't even exist in nature.

Man,
We're just trying to stay alive.

reply to post by annoyedpharmacist


I don't get it, if I pay for insurance I expect to get the best care I am paying for, is not free, why the government have to monitor what kind of medications I am to have and should I get.

I tell you this is nothing but playing games with people's health, the government will dictate if you can take or not a medication even if you are paying for your insurance.

What the heck. right? I imagine is going to get worst if you need a surgical procedure and have to be approved by the government first, so that means if you are in danger and in need good luck with Obamacrap even if you are paying for the insurance.

What a joke.

If I am paying for insurance out of my pocket I expect to receive the best care money can buy.

reply to post by marg6043


Umm... what? The government has nothing to do with PAs. It is entirely the doing of the insurance company that you pay for. Generally the purpose is to ensure that the doctor has tried cheaper therapies first or at least has justification for jumping straight in to the more expensive ones. However, occasionally you will gets ones that don't make any sense. My example from before where the insurance required a PA for generic Ambien is one of these.

Now Obamacare is a bit of a game changer. As a result we may see insurance companies requiring more PAs. However, the government isn't requiring anything. It is just the insurance companies making sure they don't have to pay out more money than they have to so they can make larger profits.

well, I suppose someone has to keep an eye on these doctors, just because they have a medical degree doesn`t mean they know what they are doing. Sometimes I think that a lot of these doctors are just googling the symptoms to diagnose the problem and then just prescribe whatever meds are recommended on the google site that they are looking at.

The insurance companies also need to make sure that the doctor isn`t just prescribing the most expensive name brand medicine because he is getting kick backs from the drug company for every prescription he writes for that medicine.