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amandagetrich's avatar

When waiting for your health insurance company to allow your pharmacy to fill a new prescription, is there any way to make the wait shorter?

Asked by amandagetrich (46points) July 16th, 2010

I was prescribed to Celexa and Adderall recently at my family doctors, and when I went to go pickup the prescriptions from the pharmacy, they said that my insurance company had to grant them access to dispurse it to me. According to the pharmacy, my doctor had to call and send over paperwork to my insurance company and wait on them to review it and grant access. Then the insurance company were to call my pharmacy and okay it for them to give it to me.

Well it’s now been five days, and I’v called and checked that my doctor sent over the information AND filed a complaint with the insurance company, hoping it would speed things up, but nothing has come out of it yet.

Does anyone know if there’s something further I can do to ensure I get my prescriptions soon?

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11 Answers

casheroo's avatar

You can pay for them out of pocket, and try to reimbursed.

amandagetrich's avatar

I never thought about that, but i’ll definetely keep it in mind, thanks!

netgrrl's avatar

As an alternative if you have to wait, as your doctors office if they have samples they can give you to tide you over.

amandagetrich's avatar

I did, however because Adderall is a stimulant, they do not carry it in the office. Thanks anyways, though.

ubersiren's avatar

Did they give you a reason why they had to approve it? Call your insurance company and get the exact reason. Have you had it filled somewhere else recently under your insurance? If so, it’s probably too soon to fill. Since Adderall is a schedule 2 narcotic there is a strict refill schedule that pharmacies and insurance companies legally have to follow to prevent abuse of the drug.

Seaofclouds's avatar

Most likely what the insurance company wanted to do was a prior authorization (that’s what they call it). I’ve had to get this as a nurse way to many times. Here’s what happens:

Your doctor writes the script.
The pharmacy submits the claim to your insurance company.
The insurance company tells the pharmacy that they need a prior authorization first.
The pharmacy tells the doctor’s office (usually the nurse).
The nurse calls the insurance company and speaks to a representative about it.
The representative tells the nurse they need to fill out a certain form and faxes it to the nurse.
The nurse fills out the form and faxes it back.
Generally at that point, insurance companies say they will respond withing 24–48 hours.
If they approve it, all is well and the pharmacy and patient are notified.
If they don’t approve it, the nurse will tell the doctor. Then the doctor will either change the script or tell the nurse to appeal the decision.
If they appeal the decision, they then have addition forms to complete and possible even other things (like getting the doctor to write a letter of medical necessity). This process can take a week or so depending on how easily the nurse gets in touch with the insurance company.
The appeal is either approved or denied. At that point, the doctor has to talk to the patient about their options.

As a nurse, I have had some prior authorizations that I was able to get within 24 hours and others that took up to 3 weeks (with the appeal). The longest without an appeal was 4 days.

Unfortunately, there really isn’t any way to make the insurance company move faster. They usually have technicians and doctors on staff that will day if there is another cheaper medication that should be tried first and often they will insist that other cheaper medications are tried before the expensive medications. It sucks!

amandagetrich's avatar

ohh thank you so much! it was prior authorization, and i’m hoping the insurance company approves it soon.

perspicacious's avatar

I imagine the drug is not on their formulary and requires the doctor’s reasoning for not using one which is. Five days is excessive though.

jazmina88's avatar

call the rx plan of your insurance company and speak with them. Keep the receipt. celexa is more expensive, get generic.

Filing a complaint doesnt work as well as problem solving with those folks on the phone.

john65pennington's avatar

Each insurance company has whats called a formulary list. if this medication is not on their list, they will not pay for the medication. there has to be a definite reason for the medication to be approved and paid for, by your insurance company.

My wife had this problem with Lannesta for a sleep disorder. it took approx. five days for Blue Cross to approve the medication and to pay for it, for my wife. this apparently is a normale procedure for insurance companies, so, your waiting time should be just about at its end.

amandagetrich's avatar

alright, thanks!

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