Ron Norman  


2305 Camino Ramon, Suite 221
San Ramon, CA 94583 (925)264-4069

 
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  Jun 24, 2017
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Prior Authorization Information

This year the number of Prior Authorization requests coming from the insurance companies more than tripled and lately we  were receiving authorization requests and denials for generic forms of medications that have been on the market for decades. Recognizing that trend, American Psychiatric Association issued the following:

Position Statement on Prior Authorizations for Psychotropic Medications, © Copyright, American Psychiatric Association, all rights reserved.
Approved by the Board of Trustees, July 2014
Approved by the Assembly, May 2014

Position Statement
The American Psychiatric Association is opposed to any requirement of prior authorization for psychotropic medications prescribed by psychiatrists prior to payment by insurers, except for instances of clear outlier practices or an established evidence base which implicates concern for patient safety. In those instances, the decision to require prior authorization or documentation should be made only by a Board Certified Psychiatrist.  

In California, prior authorization process depends upon if your insurance company is regulated by the Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI). The DMHC regulates HMOs and some Blue Cross and Blue Shield PPOs. The CDI regulates PPOs, including some offered by Blue Cross and Blue Shield.

If you are in a plan regulated by the DMHC, then you are protected from drug switches. The law provides that such plans may not limit or exclude coverage for a drug for an enrollee if:
a)  The drug was previously approved for coverage for the enrollee’s medical condition;
b)  The patient’s doctor continues to prescribe that drug for the enrollee; and
c)  The drug is appropriately prescribed, considered safe and effective for that condition.

In this case, you are protected by the continuity of care law.

AB 974 (Gallegos, Chap. 68, 1998) – Prescription Drug Benefits.
(Added Health and Safety Code Sec. 1363.01, 1367.20 and 1367.22)
http://www.cahu.org/downloads/legislation/CA-Mandated-Benefits-1989-2005.pdf
Previously approved drugs cannot be excluded from coverage.
Health & Safety Code §§ 1363.01, 1367.20, 1367.22 (AB 974, Gallegos), 7/1/99 –
Prohibits health plans from limiting or excluding coverage for a drug if the drug previously had   been approved and the plan’s prescribing provider continues to prescribe it appropriately, and it is considered safe and effective for the enrollee’s medical condition by the FDA.

If your plan tries to switch drugs, you can protest with a letter.
(See Request for Continuation in Drug Coverage below)

If you are in a plan regulated by the CDI, then you have no similar protection, although if the drug gets removed from the formulary, plans should give you the right to appeal for medical necessity reasons. However, if a drug is switched to a more expensive tier, the cost of the drug may be too high. In that case, the switch could mean that, from a practical standpoint, you cannot get your drugs.
(See Appeal of Coverage Decision Regarding a Specific Drug below)

Letter 1:  Request for Continuation in Drug Coverage

 [Today’s Date]

Re: [Your Name]
[Your Insurance Carrier / Health Plan / IPA Name]
Insurance ID Number: [Your Insurance ID Number]

Dear [Medical Director’s Name],

I have been prescribed [Name of Drug] for the past [timeframe that you have been taking the drug] for [name of your medical condition]. Up until recently, I have received appropriate coverage from your insurance company for this important medication. However, I was recently informed that the drug [has been taken off your formulary / has been moved to a more expensive copayment tier]. This change makes it impossible for me to get this medication and receive appropriate treatment

Given that this medication was previously approved for coverage for my condition, the law entitles me to a continuation of coverage under the same terms and conditions that existed prior to the change where
(1) my doctor continues to prescribe that drug for me, and
(2) the drug is appropriately prescribed and considered safe and effective for treating my condition.  Health & Safety Code §§ 1363.01, 1367.20, 1367.22 (AB 974, Gallegos), 7/1/99 that prohibits health plans from limiting or excluding coverage for a drug if the drug previously had been approved and the plan’s prescribing provider continues to prescribe it appropriately, and it is considered safe and effective for the enrollee’s medical condition by the FDA.

In other words, previously approved drugs cannot be excluded from coverage.

As I respond well to this medication, my physician continues to prescribe it for me. Should you have any further questions, my physician’s name and telephone number are [Your Physician’s Name] and the address:

East Bay Psychopharmacology Group
2305 Camino Ramon, Ste 221, San Ramon, CA  94583
Email: EBPGoffice@comcast.net

Under these circumstances, I am entitled to a continuation of my former coverage for this drug. Please contact me to confirm this fact. I can be reached at [your phone number].

Thank you very much for your attention to this important matter.

Sincerely,

[Your Signature]

[Your Name]

cc: [Your Physician’s Name]


Letter 2:  
Appeal of Coverage Decision Regarding a Specific Drug

[Today’s Date]

Re: [Your Name]

[Your Insurance Carrier / Health Plan / IPA Name]

Insurance ID Number: [Your Insurance ID Number]

Appeal of Determination Regarding [Name of medication ]

Dear [Medical Director’s Name],

My physician believes it is medically necessary that I take [name of medication]. Unfortunately, I cannot access this medication because of your company’s decision to [action taken, e.g.: not include it on your drug list / place it on an expensive tier / require that I take other medications first]. I am writing to you to appeal this decision.

[Name of medication] is medically necessary in this case because it is the best and most effective medication for my condition. Indeed, a number of studies have recommended this particular drug.
Further, the pharmacology of the drug your company is requesting that I take may be potentially harmful to me. I have little tolerance for any changes in my medications and I have experienced  negative side effects due to changes in drug regimens in the past. Other harmful effects include [list other negative effects].

In addition, covering this medication now would be in your company’s economic interest because [discuss any potential cost savings, e.g., the drug should make me healthier quicker / reduce the likelihood of hospitalizations].

My prescribing doctor clearly stated that my taking [name of medication] is in my medical best interest. My physician’s name is [Your Physician’s Name] and can be reached at
East Bay Psychopharmacology Group
2305 Camino Ramon, Ste 221, San Ramon, CA  94583
Email: EBPGoffice@comcast.net

Thank you for your reconsideration and prompt attention to this matter. Please let me know if there are any additional steps I should take for this appeal.

Sincerely,

[Your Signature]

[Your Name]

cc: [Your Physician’s Name]

_____________________________________________________________
_____________________________________________________________

 

Helpful links: 

BlueShield of CA:  https://www.blueshieldca.com/bsca/pharmacy/faqs/drug-prior-authorization.sp

California Governor signed SB 866 into law, mandating the use of a uniform prior authorization form for prescription drug benefits, streamlining and improving the process:  Prescription Drug Prior Authorization Request Form was finalized and adopted by the California Department of Managed Health Care in May 2014.

FDA says generic Bupropion XL is not bioequivalent to brand Wellbutrin® XL

 

 

 

 

 

 

East Bay Psychopharmacology Group, Child, Adolescent and Adult psychiatrists serving East Bay Area, San Ramon, Pleasanton, Dublin, Danville, Alamo, Walnut Creek, Castro Valley, Livermore, Concord, Hayward, Fremont and other local communities.

 

 

 

 

The masthead painting is by Ron Norman, a well-known artist of California landscapes.