Why your health insurance requires prior authorization for some medications

After I left Kaiser for a PPO I learned one of my anti-seizure medications is considered a "controlled substance"... and I would have to jump through hoops to get it approved by my new insurance company.

The two drugs I take to prevent seizures are Keppra (levetiracetam) and Vimpat (lacosamide). Keppra has been around for a while and is known for it's efficacy in preventing seizures. Vimpat, on the other hand, is a newer anti-epileptic drug, and is a federally controlled substance because it can be abused or lead to dependence by people who do not have epilepsy. Even the Vimpat website advises patients to store Vimpat in a "safe place, to protect it from theft."

Due to its status as a federally controlled substance, my insurance requires my doctor to get "prior authorization" from them before calling in my prescription.

Prior authorization means exactly what it sounds like: If a medication is not on your insurance company's pre-authorized list, your doctor needs to prove to your insurance company that the prescription is "medically necessary."

The following story is about the hoops I jumped through to receive prior authorization for Vimpat.

"The most beautiful data"

What I took to the appointment when seeing my new primary care doctor.

Less than one month after being on my new PPO plan I made an appointment to establish a relationship with a primary care doctor, Dr. L. For this first appointment I brought along digital copies of my complete medical record, and my prescriptions in their original bottles so I could prove to this new doctor that these are my current medications. Dr. L was very thankful for this information. She said, "You have the most beautiful data I have ever seen." I thought this was the best compliment ever.

I told Dr. L I was due to run out of Keppra and Vimpat before I would be able to establish a relationship with a neurologist. And oh yeah, I found out I would need a referral from the primary care doctor to make a visit with the neurologist.

SIDEBAR: When switching to a PPO, I was under the impression I could make appointments with anyone I wanted. Apparently, that is not the case. I still needed a primary doctor to make the referral, but I could tell her where I wanted to go.

Fortunately, Dr. L agreed to call in the prescription refill for me... to any pharmacy I wanted! That was pretty cool. When I was a Kaiser patient I had to use their pharmacies and the locations weren't always convenient.

Dr. L called in my prescriptions, I left the appointment, and all was good. That is... it was all-good until I had to pick up my prescription.

"You need prior authorization"

When I went to the pharmacy (a Walgreens conveniently located near my house) the clerk said my Keppra refill was ready, but that I would need prior authorization to get the Vimpat.

Our conversation went something like this:

Pharmacy clerk: You need prior authorization to get the Vimpat.

Me: What is that?

Clerk: What is what?

Me: What is ‘prior authorize-whatever?'

Clerk: Prior authorization.

Me: Yes, what does that mean? I have never heard of that before.

Clerk: You need to call your doctor and have the doctor call the insurance company and get authorization from the insurance company that they will cover the co-pay on this medication.

Me: So, I need to go back to the doctor and ask them to do one more step before I come back and try to pick up this prescription again?

Clerk: Yes. Ask them to get the prior authorization.

As a person who was part of the Kaiser HMO world my entire adult life, I had never heard of such a thing before. Just this past week I learned that Kaiser trusts their doctors to make the right call and the pharmacy rarely questions the orders. Regardless, the patient is never privy to these conversations... we just pay for our prescriptions and walk away in blissful ignorance.

Asking for prior authorization

I called my doctor's office from the Walgreens parking lot. I was on hold for a few minutes, and then when I spoke to a person I told them I needed this prior authorization-thing. The person on the other end of the phone seemed in disbelief.

"You mean Dr. L didn't know you would need prior authorization?" I then explained that I am a new patient and this is a special drug and I am sure she never ordered it before. The phone person said she would get a message to Dr. L and that she would get it handled within the next day.

Six days later I emailed Dr. L and asked for a status update on the prior auth (and yes, I am into the lingo now, so I can say prior auth). Radio silence.

Eight days after that I called Dr. L's office and pulled the brain cancer card. I told the phone person that I was waiting for a response, that I needed this refill ASAP, and if I didn't get it I could have a seizure, get my driver's license suspended and lose my job. I am slightly ashamed I had to pull the brain cancer card, but it always works.

The phone person apologized and said Dr. L was now on vacation so she was going to have another doctor handle it.

Doctor #2 contacted me the next day via email and said she was having trouble getting the approval. She asked if I could help explain why Vimpat was ‘medically necessary' for me.

I immediately saw what was going on: I am a new patient. It is kind of weird for a person to roll into a new primary care office and be like, "Hey guys. Hook me up with a controlled substance. I know I brought you my medical records, but you don't even know me... so... get me that prior auth."

I am slightly ashamed I had to pull the brain cancer card, but it always works.

Me waiting for Dr. K.

I replied to Doctor #2's email with a detailed narrative about my health status, all of the other anti-epileptic medications I have tried, and why they did not work. I also provided her with a timeline illustrating when I tried these other drugs. Doctor #2 responded to my email saying that my detailed narrative was helpful and that I should expect an approval soon.

Exactly 20 days after my visit with Dr. L I was scheduled to meet a new neurologist, Dr. K.

I had a great first visit with Dr. K. We reviewed my medications and he asked if I needed refills. I told him about the run around with the prior authorization. He said, "I am looking in your chart here and someone added the prior authorization number. Do you want me to write that down for you?"

I was like, "What the hell?" Apparently, Doctor #2 successfully received the prior authorization but no one called to tell me.

I left Dr. K's office with a prior auth number and headed over to Walgreens.

Vimpat? There's a coupon for that

Upon check out at Walgreens, the clerk told me my co-pay for Vimpat would be $80. My jaw dropped.

I knew generic drugs under my new PPO would be $20 (versus Kaiser's $15). My co-pay for brand name drugs at Kaiser was $40. But $80 for a 30-day supply of Vimpat? What the hell?

But then I remembered an email I received from my buddy (and fellow brain tumor survivor) Charlie Blotner a few weeks previous. Charlie knows I take Vimpat and emailed me a coupon they found on the Vimpat website.

At the time I thought, I don't need this. I have health insurance. But I was wrong. I needed it.

So I left the pharmacy, drove home, printed out the Vimpat coupon, and headed back to Walgreens.

After waiting in line again, I handed the coupon to the clerk. She looked at it for a minute, made some adjustments in the computer, and suddenly my Vimpat prescription was $20. The coupon is good for an entire year.

Needless to say, I felt like I got away with something awesome, and headed out of Walgreens as fast as I could before they asked for the remaining $60.

Moral of the story

If there is a moral to this story, it is this:

If a person like me can have trouble navigating the complicated nuances of health insurance, prior authorizations and payment, then how can we expect people who don't come from "a place of privilege" to manage their health care?

What about you? Have you ever had to deal with the delays of prior authorization? How long did it take you? Did you have to pay extra for the prescription? And if you feel like sharing, what drug needed authorizing?

More to be discussed on the topic of privilege in health care in a future blog post...