Alicia: UnLeashed! January 2018 monthly article

This weekend I watched The Greatest Showman, and as I watched Hugh Jackman sing and dance about the birth of three ring circus I could identify. Living with chronic disease is a lot like being a ring master, bringing order to the chaos of a whirl of doctors, pharmacies, insurance reps, new meds and technologies. But unlike Mr Barnum we are also lion tamers, high wire walkers, acrobats and managing ticket sales. On our best days we do it all while entertaining the crowd and no-one notices a single glitch. Other days we sit in the rubble of our circus wondering how we’re going to find the resources to make it happen again.  So I thought I’d share some back-stage secrets to  help you out. Because much like a circus the medical world comes with its own lingo, gate keepers and  rings of fire.

Tips to getting prescriptions filled:

Insurance companies contract for services and products with individual companies, and pharmacies. They then compile lists of approved goods and services. Medications are typically further classified as preferred, or in tiers.  Basically the medications that the company has the best contract on are pricesd cheapest to save the company money. This has little to nothing to do with how new the medications are as older medications are often covered at higher cost or not covered at all depending on the contract the drug company agrees to. (If they want to sell a new med they negotiate a worse contract on an old one)  If a medication is covered under any given tier you are pretty much stuck with that pricing since you agreed to it when you contracted with that insurance company.  (Which is why it’s a good idea to check where your most common medications fall in the payment structure of an insurer before signing on). But all pharmacies are not equal. You can also shop your meds around to different pharmacies for improved costs.

What about when your insurance does not cover a medication? Never stop there! Just because the pharmacy tech tells you it will cost $$$ to fill the prescription because it’s not covered by your insurance does not mean the conversation is over, it has just begun! First ask them why it is not covered, and to please print you a copy of the insurance refusal.  Typically a prior authorization is required. The prior authorization is just a form that is sent to your ordering physician. Your insurance company is betting that the added paperwork will convince you and your doctor to go with a cheaper drug. Some medications require that you’ve tried cheaper versions first, or have a medical need for that specific medication.

Time to play ring master! Don’t leave this part to the pharmacy! Neither the pharmacy nor your doctor have anything to lose by you not getting a specific medication, you DO! So ask the pharmacy to send the prior authorization request to your doctor immediately. Then call your doctors office and let them know that a prior authorization is needed and that you would like it processed as soon as possible and leave your contact information for them to call you if there is an issue. You would not BELIEVE the number of faxes that come through a doctors office, this call makes it less likely that your issue will not simply be in a sea of papers that may or may not get seen that week.

You can also encourage the doctor to use a more strategic diagnosis to justify the medication. For example if you are trying to get a blood sugar lowering medication approved, using a diagnosis of DKA (if you’ve ever been hospitalized for this the diagnosis is still usable) will be more likely to get an approval than “uncontrolled DM) likewise the specific diagnosis of “Hypoglycemia” is more likely to get an approval than “Diabetes type 1” Diabetes is a diagnosis of management, but DKA and hypoglycemia are life threatening and require a response, so they are given a much wider range of approved treatments and services. Likewise if you have been diagnosed with any complications due to diabetes that can be reduced or improved by the medication being sought include that.  Prescribers have a LOT going on, the more information you can spoon feed them in a message, the less time they have to spend digging through your chart and getting creative. Help them and they will have more time to help you! Likewise, if the insurance company requires that you try alternate medications be prepared to give your prescriber dates when you tried those medications and reasons they did not work. Once again you are saving them a trip through your chart, particularly if the trial was with another doctor or previous practitioner.

Now follow back up with your pharmacy. Never assume that things are happening. Tag back in over the next 48 hours to make sure things have moved along unless you’ve been told by one party or the other it will take longer. (But, if they say 5 days, be on the phone on day 5)

If a pharmacy says they do not stock a drug, ask them about specialty order. Just because it is not on the shelf does not mean that they cannot order it in. It will take longer, and probably a few more phone calls.

When no doesn’t mean no:

There is a great scene in The Greatest Showman where Barnum is talking people into joining him. They ALL say no, but that’s never the final answer. A great ringmaster doesn’t take no for an answer when there is any chance to make it a yes! If your insurance company has refused either a medication, diagnostic test or procedure there is a set appeals practice available. Again, they are banking on you giving up. Don’t! Use that appeal!  Often just putting in the effort, changes a no to a yes. Reach out to your ordering physician and ask them to stand with you. After all, they ordered it, so they clearly felt it medically necessary to do so! A great tip here is to call the appeal or customer service line for your insurer and ask for “the credentials and contact information for the medical decision maker for this denial” feel free to jot down that little turn of phrase and use it when needed.  We often think that these decisions are made in big medical lecture halls, or around board room tables. However, quite often they are made by nurses reviewing a file. You’d be amazed how many times just having the knowledge and experience to ask that questions has suddenly and mysteriously caused an insurer to change their mind and give an approval. This also gives a specific individual for your doctor to contact to justify their professional decision making and prescribing practice.

Asking permission is better than begging for coverage

Always remember, when the dust settles YOU are the primary payer. So any bill left over leaves you holding the bill. For any procedure, lab work, diagnostics, or new doctor, it is always the best idea to ask for the office to get approval of coverage from your insurance company before you show up.  imaging centers and surgical centers are supposed to do this a week before you walk in, but there is not always a week to wait, and it does not always get done. It will save you a lot of headache if you request this information in advance.  Most insurance companies now require an authorization for imaging, nonemergency surgery, and even many lab diagnostics.

Being a ring master isn’t easy, but it beats the alternative:

I know, you’re thinking ‘I don’t have time for all these calls, all this work! I’m barely keeping my blood sugar off the ceiling and myself off the floor!’. Believe me, I hear you. I’m a new mom, in grad school, working 40 hours a week, managing this and other medical needs, while trying to keep friends and family, faith and sanity in balance. Being a ring master is not easy! But there are only two alternatives. One is to let someone else be the ring master. The reality is, if you’re not running this show you’re left scooping elephant pooh, because when someone else takes control of the show they bring in their own cast and crew. The other option is to let the show run wild, and that is how people get hurt. Not mastering the circus of your diabetes means that you don’t get the medications, services, treatments, diagnostics, preventative care and respect that you need and deserve. Not being the ring master means that what could be a high energy show can quickly turn dangerous leaving you with damage not only to your health, but also to your financial life, your credit and your self esteem.  So allocate the time and energy when you’ve got it and seek it out when you do not.  There are lots of services both private and public out there to help. So put on your top hat and take your place in the greatest show on earth, your life.