Drug authorization is a new twist in the never ending increase in health care cost in the United States. It has come about only in the last few years since the advent of managed drug payment plans offered by health insurance carriers.
Drug payment plans are a form of cost containment by insurance companies. The companies contract with leading pharmaceutical companies who will bid on the lowest price for a particular drug. Those companies that bid lowest are contracted with the insurance company to supply their particular drug at a "rock bottom" price. This becomes the “formulary” or “preferred Tier 1” drug if you have a prescription plan that has tiers.
Certain drugs have over-the-counter (OTC) equivalents. Examples are allergy medications or medications for acid reflux. When there are multiple equivalents of a medication as an OTC product, insurance companies are reluctant to contract with pharmaceutical companies for the prescription form of the medication.
After multiple complaints by patients regarding non-formulary medication, managed drug payment plans have instituted Drug Authorization Policies. They claim that these policies allow you to have non-formulary drugs covered under your plan as long as the company reviews the need for the drug based on your doctor’s notes and needed forms. We find that this process of "authorization" delays your ability to get the needed medication and is a stall tactic on the part of the insurance company to avoid covering a medication. These tactics also are in place so you might consider using an over-the-counter alternative while you are waiting for your authorization to come through.
As a rule, due to the high volume of requests, the doctors and staff at Northern Jersey ENT do not authorize non-formulary medications. Our recommendation of medication is always what we feel will best treat your condition and is for your benefit, even if we decide to switch you to an equivalent medication that is on your plan’s formulary.
If you are given a prescription that is not covered by your plan and you are able to find a similar medication that may be covered, we are happy to give a new prescription for the one that is covered provided it works as well as the original one prescribed. You can assist us in this by having your pharmacist call us as he often has the list of drugs approved on your formulary.
In select cases we will assist you in obtaining a non-formulary medication if we feel that the non-formulary medication is equal to or better than the one prescribed. You can help us in this task by getting the needed paperwork from your insurance company.