What’s the deal with prior authorization? Why is it always a pain?

So I switched insurance plans effective November 1 and I still haven’t been able to get prior authorization for my Humira at Duane Reade, my pharmacy of choice in NYC. For those of you who don’t know about this process or are new to it – you can fill biologics at your pharmacy for a few months and then (you will get rejected and be unable to fill it there anymore) you will need to switch to a mail order pharmacy. This process is very difficult because you need prior authorization from your doctor for the pharmacy and the mail order pharmacy. This means you need to fight TWICE to get your medicine.

I had to get Humira samples last month from my doctor and will need to do the same this month. Yesterday, I called to follow up regarding the status of my Humira and was told the prior authorization takes months and to make sure I don’t lapse on taking my Humira I need to arrange to pick up samples again.

Why does prior authorization take months? I follow up with the doctor’s office to try and speed along the process. The pharmacists are on top of it and address it with me every time I’m picking up medicine, which is weekly. I do all I can but I have no control over when I will get my medicine. All I can do is continue to get samples of my Humira and fight for prior authorization until it is granted.

I hate to sound like I’m so aggressive and obnoxious because I am not, but when it comes to my medicine that allows me to move and function I will do whatever I can to be heard.

Here is my advice to make sure the process of prior authorization (PA) goes as well as it should:

  1. Continue to call and follow up with doctor’s office weekly or sometimes every few days.
  2. If you have a portal where you can request refills request updates re: PA – I do this on NYU portal all the time – use the portal.
  3. Work with your pharmacy to make sure they can do whatever possible to help speed the process along – my pharmacists have become my buddies and are always advocating for me.
  4. Know this process is stressful and will need a lot of time, patience and attention.
  5. Make reminders to follow up with doctor and pharmacy so you don’t go two weeks without an update.
  6. Don’t give up and ALWAYS ask doctor for samples so you don’t miss taking your medicine.

asbRA was diagnosed with RA in November 2012 at the age of 27 and fibromyalgia in 2013. Through therapy and MBSR meditation asbRA found her calling in journaling her experience and is writing a book on how to navigate an RA diagnosis in the prime of one’s life. As a strong advocate in the autoimmune community asbRA shares her wisdom in hopes of helping others. @AllisonSBerger

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