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A New Kind of Prior Authorization Hassle

Drug Benefit TrendsDrug Benefit Trends Vol 21 No 7
Volume 21
Issue 7

I hear from my physician friends that the “hassle factor” to obtain health plan coverage of prescribed therapy is increasing exponentially and that many of them are thinking of retiring or cutting back their practices. That is my experience and reaction as well.

I hear from my physician friends that the “hassle factor” to obtain health plan coverage of prescribed therapy is increasing exponentially and that many of them are thinking of retiring or cutting back their practices. That is my experience and reaction as well.

Just this week I was confronted with yet another new drain on my time, courtesy of misguided cost containment efforts by drug benefit managers. For the first time, I was asked to complete a prior authorization process for an ogoing prescription for generic methylphenidate. Let us track this latest hassle factor to see how well-meaning initiatives are slowly paralyzing the medical care system.

My little adventure began with a fax from a local chain pharmacy alerting me that a prescription I had written for a generic sustained-release methylphenidate needed prior authorization. That was peculiar, since my patient had been taking the same medication for years. When I called the pharmacy, I learned nothing more except that the drug benefit manager (CVS Caremark) had rejected the prescription claim and that I had to call an 800 number to obtain prior authorization. So I called the number and negotiated the automated telephone menu system.

After waiting on the telephone for the next available person, I was finally greeted with a request for the patient’s ID number, date of birth, medication in question, my name, title, address, telephone number, fax number, and so on, only to be told that she, too, did not know why a prior authorization request was now needed but would be sending me the form shortly. When I asked whether I could prescribe another sustained-release methylpheni- date formulation that might not require a prior authorization form, she said she would connect me, but that department was backed up with calls. Because that department was very busy, she would be sure to send me the form in case I did not get through to them. After an additional 5 minutes of nondescript music on hold, I hung up without making the connection.

In the meantime, my patient called. She was quite upset because she could not get her prescription filled and was told that I had not yet filled out the necessary prior authorization forms. I explained that I was trying to resolve the situation and get her prescription filled, but it was not so simple. My patient reminded me that she needed the medication not only for her long-standing attention deficit/hyperactivity disorder (ADHD) but also because in the past when she did not have the medication, she became severely depressed. Indeed, I was prescribing methylphenidate in conjunction with extended-release venlafaxine to keep this patient from becoming severely depressed and suicidal (requiring hospitalization in the past).

That afternoon and the next day passed and again the patient called to remind me that she still could not get her prescription filled. I called the 800 number, negotiated the automated telephone system, and was asked the same questions again, only to be told that they were very busy and I would be getting the form within 24 hours. When I stated that it had already been longer than that, the person (of course not the same person I dealt with the first time) said that it was 24 “business hours.” I asked what that meant and found out it was “within 5 days” (because there was a weekend involved and business days count as 8 hours each).

The next day, now the third day (in real time!), I finally received the form, which proved simple to fill out. Then I got my real shock-the prior authorization request was not to justify the need for a particular methylphenidate preparation that for some reason was not on the proprietary formulary, it was something new entirely. This form was from CVS Caremark in conjunction with Medicare (Prior Authorization Form: The Joint Enterprise Medicare Advantage).

Now I had to complete a form swearing that I would “regularly monitor the patient for adverse events, including weight loss and decreased growth velocity for children, increased heart rate and blood pressure, the appearance or worsening of aggressive behavior or hostility, sleep disturbances, and long-term usefulness of the drug.” As I put in the comments section of the form, why would I not monitor this patient and why would they delay my patient’s prescription for this specific testimonial? They were wasting my time and upsetting my patient for no good reason that I could see.

Furthermore, another section of the form required me to state that the patient was not taking a monoamine oxidase inhibitor (MAOI) while receiving this therapy and had not taken an MAOI in the previous 14 days. Actually, whoever made up this form is ill-informed. The particular patient in question, before being treated with venlafaxine, had taken tranylcypromine (an MAOI) and methylphenidate safely for many years. In fact, specific literature attests to the efficacy of this combination for treatment-resistant depression. Used carefully at low dosage, it is quite safe (even though the Physicians’ Desk Reference warns of the use of sympathomimetic drugs with MAOIs).1,2

So, I respectfully ask, who should make the determination about which drugs to administer, to whom, and in what combination? Is a generalist physician likely to prescribe an MAOI? I doubt it; more likely, it would be someone like myself, a board-certified psychiatrist who has extensive psychopharmacological training and experience.

My argument is not that any one attempt to standardize treatment and safeguard the public will destabilize the system but that all of them together drain time and become hoops for busy physicians and pharmacists to have to jump through. The public is not safeguarded when ill-conceived forms are filled out angrily and patients have to worry about when and whether a needed prescription will be available for them to pick up at the pharmacy.

This problem is not limited to only CVS Caremark. Recently, I received another time-wasting and frustrating request for a prior authorization from a local pharmacy. This time, I had to call Medco for a patient for whom methylphenidate extended-release was prescribed, 40 mg once per day for 30 days (which was on the list of preferred medications). That resulted in a 10-minute “dialogue” with an automated telephone system that eventually allowed me to speak with one person and then another.

After giving my name, address, telephone number, fax number, patient’s name, insurance number, address, home telephone number, date of birth, and the medication name and dosage 3 different times, I finally got to the approval process. That meant 4 questions from the second live person. The questions were for the diagno-sis (ADHD), the medication name and dosage (meth- ylphenidate extended-release, 40 mg) and directions (every morning), whether there were any contraindications (none), and whether the prescription was necessary (yes). As I responded when asked if I needed anything else, after being granted approval for the prescription for 1 year, “Why would I be prescribing the medication if it were not needed or there were contraindications?” I received no answer and soon received a fax confirming approval.

Drug benefit managers have apparently targeted psychostimulants for a new level of review and hassle. Now, physicians not only have to write out monthly hard copies but also must attest either verbally or on paper that we are prescribing medication for an approved use, without contraindications, and that we are monitoring for safety. Why are drug benefit managers entering into the physicians’ area of responsibility and wasting pharmacists’, patients’, and prescribers’ time? Where will I get the extra (unreimbursed) time to do this? Perhaps I should cut my patient sessions even shorter than they already are!

Marsha Moore, MD, senior vice president, Medical Affairs, at CVS Caremark, replies:
As a pharmacy benefits manager, CVS Caremark has a responsibility to help ensure that our clients’ (eg, health plans, employers) benefit plans are well managed from a safety, efficacy, and cost perspective. To achieve this goal, our clients may request that CVS Caremark administer various tools, such as retrospective review, gaps in care identification, and prior authorization (PA).

While PA is an important tool for helping to ensure quality and manage costs for pharmacy care, we recognize that, at times, it may result in additional administrative activities for physicians. We work continuously to find ways to improve the experience for physicians and patients. For example, we are currently working to simplify PA criteria questions and are coordinating pilot programs that enable PA activities to take place via electronic prescribing. In addition, from a clinical quality and safety review perspective, our PA programs undergo both internal and external physician review for appropriateness before implementation and are reviewed regularly.

With regard to this specific example, this plan participant’s Medicare plan began requiring PA for methylphenidate prescriptions as of January 1, 2009. The plan utilized a PA process administered by CVS Caremark, and we processed the prescription accordingly.

Our standard Medicare PA criteria undergo review by an external independent P&T (Pharmacy and Therapeutics) Committee, external experts, and the Centers for Medicare & Medicaid Services. They approve all of our criteria on a safety and effectiveness basis. The MAOI scenario mentioned was recently reviewed by our external consultant psychiatrist, who recommended continuing to include it in the PA criteria, because not all methylphenidate prescriptions are written by specialists, and some generalists who write these prescriptions may not be aware of the MAOI contraindication in the FDA-approved labeling for methylphenidate.

Finally, this physician’s experience related to the efficiency of the actual PA process (eg, lengthy on-hold time) is unfortunate and is an aberration. According to our statistics, during the second quarter of this year, physicians or their representatives were able to complete the PA process by phone in approximately 3.5 minutes, including hold time, with an average hold time of 14 seconds.

CVS Caremark takes feedback from practicing physicians very seriously, and we have a provider relations group that evaluates the root causes behind issues raised by practicing physicians. The feedback provided here is appreciated and will be used to continue to improve our PA processes.


1. Feighner JP, Herbstein J, Damlouji N. Combined MAOI, TCA, and direct stimulant therapy of treatment-resistant depression. J Clin Psychiatry. 1985;46:206-209.
2. Physicians’ Desk Reference. 63rd ed. Montvale, NJ: Thomson Reuters; 2009:1533. 

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