(Oona Zenda/KFF Health News)
A woman with multiple sclerosis wanted to be able to walk up the stairs at home without losing her balance. Her doctor prescribed medicine that helped, but then approval from her insurance plan for the drug expired.
“Why do I need a prior authorization for something that I am already prior-authorized to take? If my doctor says that they want me on a medication, why does my insurance have another say in that?”
— Jaclyn Mayo, Lunenburg, Massachusetts
Jaclyn Mayo has multiple sclerosis, an autoimmune disease that damages the nervous system and can mess with coordination and balance. To get steadier on her feet, Mayo had been trying to lose weight: A lighter body puts less stress on the joints and leads to greater flexibility.
After Mayo didn’t have much luck with diet and exercise, her physician prescribed Zepbound, a GLP-1 weight loss medication that suppresses appetite.
“It was really helping me,” she said. “I could go up and down stairs and not feel like I was going to fall.”
As a happy bonus, the GLP-1 seemed to ease other MS symptoms for Mayo: She started sleeping through the night, and the frequent numbness in her hands went away.
After being on Zepbound for seven months, she fell into an insurance pitfall: prior authorization.
In August, her pharmacy wouldn’t refill her prescription, and it wasn’t clear why.
She called her pharmacist, then her doctor’s office, the pharmacist again, then her insurance company. After speaking with the insurance company’s pharmacy benefit manager — a third-party company that oversees prescription drug plans for insurers — Mayo figured out that the advance approval her insurer had granted for the drug, known as prior authorization, had expired.
Insurers require prior authorizations for certain treatments or tests, especially costly ones. When they do, your doctor has to make the preauthorization request to your insurance company, explaining why you need the treatment. Next, the insurer decides if it agrees that the care is medically necessary and if it will pay for it.
Mayo had been taking the weight loss medicine for less than a year and didn’t understand why a new prior authorization was needed so soon. She said she never got a letter or email notifying her that the clock had run out on her first prior authorization. As someone with a chronic illness, Mayo said, she keeps close track of her medical paperwork. She feels like she did everything right, which, she said, made the situation especially infuriating.
Her doctor submitted the necessary paperwork then found out the new approval would take seven to 10 business days.
At this point, Mayo had been off her medication for two weeks. Her sleep was getting worse, and the tingling numbness in her hands returned. So she asked that her prior authorization be expedited, only to learn that her doctor, not Mayo, would need to make the request for an urgent review.
“That red tape was completely avoidable,” she said. “And all that they needed to do was communicate clearly to me. And then I could have continued my medication without delays. But they didn’t.”
Why Insurers Want Prior Authorization
Doctors are often frustrated by the prior authorization process, but insurers argue it helps keep costs down.
AHIP, the insurer trade group formerly known as America’s Health Insurance Plans, declined an interview request. But …