I got a call today from Customer Service on the other side of the wall from me, and they had a patient on the line asking if we could issue an emergency supply of Expensiva, a costly injectible medication for arthritis, psoriasis, Crohn's Disease. I asked if we had received a Prior Authorization request and she stated that the MD office is closed for the holiday and won't be in until Tuesday so has not submitted it yet. The patient is pleading that we give them an emergency supply, there is a major flare occurring, they are bleeding, and in much pain. Based on the diagnosis I knew this was a lost cause, but, being the thorough person I am, I asked RedBull if we could accommodate the patient.
Here's how that went:
RedBull: have they had it before?
Honeybee: According to our records, nope.
RedBull: Was there previously a grandfathered PA even?
RedBull: So, they want us to issue an emergency supply for a new start of Expensiva which costs thousands of dollars, you cannot break the box, and must fill the whole kit for a non-life-threatening diagnosis?
Honeybee: That's what it sounds like to me unless they got it under another insurance coverage which explains why we don't have claims history.
RedBull: That's a possibility. The emergency supply is not gonna happen.
Honeybee: that's what I thought but I just had to make it "official" by checking with you. My inclination is to recommend some Polysporin and bandages for the bleeding & to have them call the MD on call to see if they could do some oral steroids to help get the inflammation down & stop the bleeding, but that's just me. Steroids will kick in fast, Expensiva needs to build up in your system, it isn't going to provide instant relief for anyone.
RedBull: good call, you need a significant raise
Callous and heartless as our exchange seems, this is reality in PA Land. If you haven't begun therapy on a drug in the recent past, we're not going to issue an emergency supply (unless we're talking a drug for a life-threatening condition) without a Prior Authorization request. Sorry!