Last Updated: Jan 17, 2018
Middletown, Pa., teenager Zachary Souders went from doctor to doctor for two years before learning the source of his chronic lower back pain: Juvenile idiopathic arthritis.
But thanks to a confusing and convoluted prior authorization process, it would be a few more months before Zachary could begin feeling relief.
Zachary’s rheumatologist prescribed him Humira in August 2017. It took his mother calling their insurance companies every day for nearly a month before they secured the prior authorizations to pay for the expensive drug.
The Souders have two forms of insurance and both initially denied their request to pay for Humira, according to Zachary’s mother, Laura Souders.
Their secondary insurance carrier said that the primary insurer should cover it. The primary insurer said the secondary insurer should cover it.
“It depended on who I talked to,” Laura said. “It changed every single day.”
Finally, Laura decided to take the afternoon off from work and, by chance, connected with a customer service rep at her secondary insurance carrier who spent three hours getting approvals from Laura’s primary insurance company.
“I just got lucky that day,” Laura said. “The insurance person seemed to know the right questions to ask and was willing to spend all that time on the phone to get this resolved.
“My biggest thing is if I had this much trouble getting prior auth, how do people get through this system when they’re elderly, or don’t have the computer skills, or aren’t as persistent as I was?”
Humira typically takes three months before patients begin feeling relief. Zachary began taking the medication in the fall of 2017. His mother said in early 2018 that the medication appeared to be working.
Has Your Care Been Delayed By Prior Auth?
Has your care been delayed by a prior auth denial? If so, we encourage you the make an official complaint to the Pennsylvania Department of Insurance. Use to this link and follow the instructions.
Your official complaint to the Pennsylvania Department of Insurance will help support legislation that could reform the prior auth system in Pennsylvania. The Pennsylvania Medical Society and its coalition of 50+ advocacy organizations support HB 1293, which aims to decrease patient wait times from prior auth and increase transparency from insurance companies.
Learn more at www.pamedsoc.org/PriorAuth.