The Mental Health Medication Preauthorization

Dr. Durruthy, does your patient need this medication? Life reminds me to adapt to change and remain flexible in order to be less stressed by the daily challenges in my profession. Nonetheless, the medication preauthorization has been a continuously harrowing adventure including ongoing changes. I am routinely asked to preauthorize medications for my patients. It may seem like a harmless request, especially to those who are naive to the process. Simply call into a toll free 800 number and verify that you ordered the medication.

If you analyze the situation, it becomes a big problem. If a prescription is rendered, a documented paper trail exists. Yet I have to find time to call into a pharmacy benefit plan for a growing number of patients. Of course cost is an issue for most companies; therefore, making the process convenient by hiring a full complement of customer service representatives is not a priority. Thus, I usually hear the customary announcement that we will be with you shortly because we are experiencing a high call volume. This can make my blood boil during a busy day. Time is valuable and this waiting exercise will cause me to be late with other patients who have established appointments. When a live person finally answers my call, additional time is required for them to locate the patient records in their data base. This exercise is predictably a total disaster for a new hire or if the patient is a spouse or child with a different last name than the insured subscriber. The process requires me to verify and update the name, address and telephone number of the subscriber. After the demographic information is given or verified, more time is lost waiting for the pharmacist to come on the line.

Depending upon the employer’s insurance medication benefit arrangement, the pharmacist may be given a golden opportunity in which to change my mind. I am asked about the patient’s diagnosis, whether I’ll be following the patient for potential side effects, and if other medication choices have been considered. I frequently think about how this preauthorization routine has become the essence of my existence as a psychiatrist.

Playing the game of preferred medication can be complex. The little known historical fact that the pharmaceutical benefit manager is often influenced by the drug manufacturer is often forgotten. In other words, a pharmaceutical company that manufactures drug X often owns the respective benefit manager. In this capacity, a pharmaceutical company can dictate that their drug X becomes the preferred medication offered to the plan’s beneficiaries for that defined illness. Other medications will be non-preferred and cost the subscriber more.

In my opinion, the future relationship between health care and technology is uncharted and bleak. As the population ages, so do the body organs including the brain. No new medications for mood disorders such as depression are on the horizon. Those of us seasoned in pharmacology have started to enter new frontiers with antidepressant medications needed to sustain those with chronic severe illnesses. Along the way, I have had the experience of computers rejecting prescribed pill counts, especially when they are indicated for those with severe illness. My patients are frequently stabilized by dosages outside of the standard amount as prescribed by those with less skill. Evidence based medicine works well if your illness is a common one which responds to agents that those with less training feel comfortable prescribing. However, what happens when your brain does not respond to the standard low dose of an SSRI (selective serotonin reuptake inhibitor)?

This preauthorization requirement combined with technology can easily track your medication and limit your choices. I have no answers for this dilemma but I do encourage you to become active and understand health reform issues, especially if your illness is chronic and challenging to stabilize.