Paralyzed by Insurance Drug Formularies? Don’t Forget Cash!

I haven’t counted how many times this happens every month, but I find it annoying:

I send a prescription for a drug (sometimes not even expensive) to the pharmacy and soon after, I get a fax asking me (or my medical assistant) to go online and print a Prior Authorization form to complete and fax to the insurer, or answer numerous qualifying questions on the screen, or (worst of all) make a toll free call and spend unpredictable amounts of time pleading to have it paid for.

My time is worth (opportunity cost) $7-14 per minute, depending on if you count only my basic (E&M) professional fees or also the ancillary revenue (lab, x-ray and additional procedure charges) I generate.

This may be for a prescription with a cash cost of $10.

Sometimes I don’t even know if the new drug I prescribe will work. In the case of self-pay, a patient can buy a few pills cash to try them, and if they work, it may make more sense for me to offer my unreimbursed time to plead for coverage.

Because, of course, the cash cost is per pill whereas the insurance copay, and the amount posted toward your total drug plan benefit, is per prescription (same cost for anything up to the allowable monthly quantity), thus counting toward deductibles and the slide toward the dreaded (Medicare D) doughnut hole.

So even if I do my patient a favor and get the new drug “covered”, they may ultimately and in reality end up paying for a month of a medicine they couldn’t use.

Even worse than my own Prior Auth faxes, sometimes a specialist prescribes something esoteric, and when they get this dreaded fax, they forward it to me.

How am I supposed to justify a drug I didn’t choose?

And my biggest gripe with Prior Authorizations is that it can be hard to figure out what is covered and what isn’t.

One of my EMRs gives me an “emoji”, green smiley, yellow quizzing or red frowney, depending on status for many insurances, but only a question mark for some. My other EMR often just claims it doesn’t know.

In the case of our biggest payer for medications, Mainecare, they avoid the Prior Auth hassles fairly well by publishing rules like:

60 days of a preferred Proton Pump Inhibitor, like omeprazole, thereafter PA if you can’t wean down to an H2 blocker, like famotidine.

Coverage for preferred stimulants only if ADHD is mentioned on the prescription.

AARP Medicare D required a phone call, with hold time, to get non-valvular atrial fibrillation to justify a prescription for Eliquis, and another Medicare D plan a similar holdup to explain Suboxone was for opiate dependence and not for pain. In both those instances, the drugs are simply only indicated for certain conditions.

There are bigger foes to contend with than the insurance companies if you break those rules…

Maybe there should just simply be a CPT code and an RVU for obtaining a Prior Authorization?

1 Response to “Paralyzed by Insurance Drug Formularies? Don’t Forget Cash!”


  1. 1 Brita Guirguis February 11, 2019 at 2:25 pm

    So true. I’ve found GoodRx.com to be a helpful resource for finding cash pricing (and also coupons) in my area. It only seems to include big box stores so it may not be helpful for all.


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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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