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    Monday, March 27, 2006

    Justifying Medicines: Word has it that the Medicare Part D insurers are making it hard to get non-formulary drugs:

    Some patients and doctors are facing a new problem with the fledgling Medicare prescription drug benefit: Medications they once received without question from other plans are being denied by the private insurers running the Medicare plan.

    When they appeal the coverage denials, the patients and their physicians face confusing forms, time-consuming demands for personal medical information and long delays.

    In some cases, the private plans won't cover the full dosage called for in a prescription or try to steer patients to drugs other than those prescribed.

    When disputes arise, doctors are asked to justify their prescribing decisions in writing, sometimes with patients' medical histories or test results as supporting evidence. Some plans even ask for doctors' notes or for peer-reviewed articles that justify their decisions.

    ``Whether intended or not, it's a process that nobody can navigate in an efficient way. It's a major problem right now,'' said Sam Muszynski, head of health-care systems and financing at the American Psychiatric Institute.

    This isn't limited to Medicare Part D, however. Since the beginning of the year, all the insurance companies have been making it harder to get authorization for non-formulary medications. Where they once just sent a fax that required answers to a series of questions, they're now requesting documentation. That means copies of the patient's chart notes. (You would think they don't trust doctors. Shocking.) It does make the process much more time consuming. But that's probably the point. They want to make it harder to get the more expensive drugs. And they want doctors to think twice before signing those authorization forms.

    posted by Sydney on 3/27/2006 08:30:00 AM 3 comments


    Just remember this when people discuss government takeover of all health care. All the bureaucracy, none of the service.

    By Anonymous Anonymous, at 5:57 PM  

    yep got a letter from my medicare prescription insurance company yesterday that my Protonix would no longer be covered.. they want me to take omeprazole instead.. now I know Protonix is one of the cheapest ones out there..maybe they would prefer to have medicare pay for bleeding ulcer that is sure to follow with no medication.. been there done that.. got the tshirt.. UGHHHHHHHHH

    By Anonymous Anonymous, at 7:27 AM  

    You asked for government regulation. You got government regulation. You can always pay cash for your protonix.

    By Anonymous Anonymous, at 8:19 PM  

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