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Everyone With HIV Needs to Know About 'Prior Authorization'

prior authorization

With disturbances to everyday life now commonplace in the midst of the COVID-19 pandemic, people with serious or chronic health conditions such as HIV should be on the lookout for potential problem areas in their health care. One longstanding health insurance procedure in particular, prior authorization, may prove more problematic than usual.

Many drugs for conditions related to HIV utilize prior authorization. These include some antiretrovirals and diabetes medications, Mytesi for HIV-related diarrhea, all pulmonary hypertension medications, many cardiovascular drugs, Triglyceride Lowering Agents, most anti-fungals, Epoetin/Procrit for anemia and Ensure and oxandrolone for cachexia. Prior authorization is a process used by Medicaid and most private insurance companies as a safety and cost management measure. In essence, before a pharmacist can fill certain medications, they must contact the insurance provider which reviews the request and most often requires clinical information from the physician before the pharmacist can fill the prescription.

Prior authorization can be required for any drug but most often is utilized for costly medications, specialty drugs or drugs not on the “preferred drug list.” This despite the main rationale used by insurance companies for the use of prior authorization which is to ensure a system of checks and balances in safely prescribing medications. In other words, prior authorization is less about safety and more about an insurance company making sure a doctor isn’t prescribing a medication that could be switched out with a cheaper alternative or a drug on the “preferred list.”

“The challenge health plans and PBMs (pharmacy benefit managers) face is how much to add to a physician’s practice,” says Brian Solow, MD, chief medical officer at OptumRX, a pharmacy care service company and an affiliate of UnitedHealthcare Insurance Company. “There is a need to ensure safety and optimal therapy, but it’s also important not to overburden practices or limit access to medications.” He adds, “Still, we have a responsibility to ensure the most effective use of medicines.”

However, many of the HIV-related medications currently requiring prior authorization are not new or unproven drugs. They are medications with a great deal of data that are commonly used, thus eliminating the benefit of prior authorization and leaving only the pitfalls. Prior authorization is known to be a tedious and time consuming process that can result in delayed dispensation of medications, which can leave a person without a desperately needed prescription for up to a week as the process between the doctor/medical staff, pharmacist and insurance company caries out.

One independent study of prior authorization concluded “… case studies of states’ prior authorization programs have observed that these programs can lead to bureaucratic and communication problems among enrollees, providers, and pharmaceutical benefit management firms under contract to the state, which in turn can lead to delays and other problems with prescription drug access.” 

The COVID-19 pandemic opens up entirely new problems in relation to therapies that require prior authorization. State governments are experiencing extreme loss of revenue due to the pandemic and extended stay-at-home orders. With millions of Americans now unemployed, more people are applying for Medicaid, unemployment and public assistance placing an unprecedented burden on state governments. Additional costs including testing, contact tracing and the care of patients are intensifying this burden. Particularly with Medicaid, costly medications requiring prior authorization may be one cost saving causalty with decisions of patient care not being made on a doctor's judgment but on a temporary economic need. The cost of prior authorization itself, which requires additional staff to manage, is an unnecessary burden on the Medicaid and healthcare systems.

Under ordinary circumstances, many physicians consider prior authorization an impediment to caring for patients and an attack on their autonomy and medical training. According to Matthew Mintz, MD, FACP, an internist in Bethesda, Md., “Prescriptions are expensive and prior authorizations are an easy way for insurance companies to save money. The process is made, in my opinion, purposefully burdensome so that the physician or patient will simply give up, and use a cheaper alternative.” 

The prior authorization process under normal circumstances is time consuming and problematic to providers and an annoyance and potential danger to patients. Patients often end up with delayed prescriptions and the responsibility for tracking down where the break in the chain of doctor's office to pharmacy to insurance company/HMO/Medicaid occurred, often resulting in no prescription days after it’s due. However, under current conditions during the COVID-19 pandemic, the antiquated practice is an even more serious barrier which could prove extremely damaging to people living with HIV and other medication controlled conditions. Accessing primary care physicians to submit the needed documentation for prior authorization may prove more difficult than usual.

Many infectious disease doctors, including HIV specialists, are now providing care in hospitals to COVID-19 patients. Others with small practices had temporarily closed their doors under stay at home orders, limiting visits and office hours. As a second wave is predicted, these closures may become common throughout the coming years. Others have downsized office staff, including those responsible for answering phones and facilitating prior authorization requests. The process of prior authorization under current conditions could lead to a greater number of people experiencing disruptions in receiving essential medications and an increase in hospitalizations.

The decision for appropriate medical treatment should be left to doctors, not non-medically trained insurance workers, particularly at a time when such interruptions in treatment can prove more devastating than usual. The leadership of the COVID-19 task force, many who have worked in the HIV field for decades, continue to talk about AIDS in a past tense. However for those struggling in an unprecedented new pandemic environment, the issues of prior authorization are very much a contemporary concern.

Jeannie Wraight is a health writer and frequent contributor to Plus. Follow her on Twitter @JeaWra.

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