Access to Medication

[Exaltist Ethan]

This is absolutely ridiculous.

I'm on a few mental health medications. They all work together to keep me sane and coherent. If I don't have even one of them, I am a mess. I go through a provider and have a doctor through them. He is virtual. I do not have his phone number or his direct nurse's phone number.

I was scheduled to get a medication today. It is an injection. My doctor authorized a new version of the medication that lasts six months. Last Friday I called it in, thinking that it would be authorized by Monday. I called my pharmacy to make sure I would get it. I have found out that my doctor did not authorize the medication, because the nurse that was supposed to do it was not working on Monday, and there was basically an auto-rejection from lack of response.

My doctor has verbally told me that I would get this medication. I trusted him. I didn't think this would be an issue so I waited until last Friday to give them the call to finalize it for me. While the doctor has the ability to send a script to my pharmacy, it is the nurse that processes the medication for insurance and without it, my medication is rejected.

I am now rescheduled with my pharmacy to get it on Friday morning. I have extra pill-form of this medication, but it will only last me five days max. I cannot afford to get more of the pill form of the medication unless it is authorized by insurance. Last time this happened I ended up getting seven pills for $83. I don't even have $83 right now due to another issue I had to resolve.

I called the nurse triage line and the general phone number to the outpatient behavioral health line at the hospital and left two voice mails. I clearly stated that I need this injection as soon as possible. It shouldn't be this difficult to access medication. If the doctor authorizes the medication verbally and sends a script to get it refilled, it should be covered under Medicaid automatically from there on.

If I do not get the injection on Friday, my pills will be gone by Monday. Without this medication I am a wreck and I've experienced extreme forms of mania and depression while it was wearing off. My pharmacy's nurse has made all lines of communication available and has clearly told me that as soon as they get the authorization for the injection, she will administer it as soon as she could. She's a great nurse.

I just don't know how soon I can get this injection. I've called the same nurses' triage line before and only have been able to get a reply a few days later. This is an emergency and I can't even be admitted into the psych ward to change my medications. If I go to an ER and get it refilled, it will still take a couple of days for the pharmacy to get it, and I will have to pay out of pocket for all the pills, something which I cannot afford to do right now.

I don't know what to do. When the medication was refused on Monday the pharmacy didn't even call me to see what I could have done about it. If I would have known Monday that it was refused, I would have contacted the nurses at my hospital to see what could be done about it. If the six-month medication injection is not available right now, I am willing to be on the three-month injection. This issue with that is, however, is in three months the same issue might happen again, so I'd rather be on a medication that lasts longer.

In the past I used to reject medication and denied that I had a mental illness. And now that I admit that I have a problem and need to be medicated, I cannot get the medication administrated to me now. Access to medications that stop me from going crazy should not be this difficult to access. I can't overdose on this medication, it doesn't even make me feel good at all. I don't see my doctor until the day before Thanksgiving this month and there is no number or anything on the website to call him again to get this issue resolved.

I tried everything else. I called an emergency line, I called other psych wards to see if they can switch me to the pill form, I even talked to some cops and in the end they all said the same thing: contact your provider. My provider isn't doing their job and making sure I'm medicated. The most I can do now is take the emergency supply until Monday, and if they still don't have the medication for me, I'll have to double-down and take a morning PRN of a different medication for the time being. I don't know what else I can do.

Access to medications that people need shouldn't be this difficult in America to get. My pharmacy should well in advance have prior authorization before my date is due and if they can't they should call me so I can figure out what to do. The best I can do right now however is wait to see if the nurses at my hospital can authorize it. I don't know how authorization works but it should not be that difficult to get a medication like this.

Next time I am due for this medication I am calling two weeks in advance to figure this out.

 

[JustGeorge]

Can you talk to a pharmacist? I'm not sure if it will do any good, but when my son ran out of something and the doctor/insurance delayed between them, the pharmacist gave him 3 extra pills to tide him over. Sometimes they can expediate things.

Another option might be to actually go into your doctor's clinic. People move a lot faster when there's a body sitting there as opposed to another name on a call back list.

Again, not sure if it will help. Just ideas.

 

[Exaltist Ethan]

Can you talk to a pharmacist? I'm not sure if it will do any good, but when my son ran out of something and the doctor/insurance delayed between them, the pharmacist gave him 3 extra pills to tide him over. Sometimes they can expediate things.

My pharmacist told me to contact my provider who can authorize the medication. They are not legally allowed to give me my medication without insurance authorization. The medication in question is $7,000 for the three-month injection and more for the six months. The closest physical pharmacy to my apartment isn't too far to walk to, but because I get an injection and not pills typically, they aren't going to give me the pill form unless I have a script for it. Which means going to the ER, and then I would have to pay it out of pocket, something I cannot do right now.

Another option might be to actually go into your doctor's clinic. People move a lot faster when there's a body sitting there as opposed to another name on a call back list.

My doctor is virtual and does not operate locally. Going to the hospital where the connection between him and I made wouldn't help because there are no doctors at the hospital who are legally able to help me.

 

[Quintessence]

I learned a lot about why this happens from my students who have worked as pharmacy technicians.

The problem is insurance companies.

At risk of oversimplifying, insurance companies create a lot of red tape which then gets passed on to your health care provider. Your health care provider doesn't get compensated for the time they have to waste working through prior authorizations of your meds with insurance companies. In most places, health care providers are overburdened and overworked. Stuff gets caught up in bureaucracy. Prior authorization is supposed to be a simple check on dispensing medications. Profit motives on the part of insurance companies, though, make the process ugly.

One of the many reasons we need public health care in this country. It wouldn't prevent the exploitation here, but it could force some much needed reforms.

 

[Exaltist Ethan]

One of the many reasons we need public health care in this country. It wouldn't prevent the exploitation here, but it could force some much needed reforms.

The thing is, there is really nothing to exploit here. The medication in question isn't a controlled substance; it's not Ritalin, or a different ADHD drug, and it's not a benzo. It's an anti-psychotic. Anti-psychotics don't make you feel good, they prevent you from feeling terrible. And it's virtually impossible to overdose on the injection. Taking more pills than prescribed doesn't really hurt you either. Now, I could definitely see if they want prior authorization for controlled substances, because there is so much abuse around those. But for any anti-psychotic or mood stabilizer it should just be a given that the person won't (and really can't) abuse those meds. I realize my medication is really expensive but it's harmless and should be treated as such.

(I realize now that you are referring to their exploitation, not my own. My argument still stands.)

 

[SomeRandom]

I learned a lot about why this happens from my students who have worked as pharmacy technicians.

The problem is insurance companies.

At risk of oversimplifying, insurance companies create a lot of red tape which then gets passed on to your health care provider. Your health care provider doesn't get compensated for the time they have to waste working through prior authorizations of your meds with insurance companies. In most places, health care providers are overburdened and overworked. Stuff gets caught up in bureaucracy. Prior authorization is supposed to be a simple check on dispensing medications. Profit motives on the part of insurance companies, though, make the process ugly.

One of the many reasons we need public health care in this country. It wouldn't prevent the exploitation here, but it could force some much needed reforms.

One of the reasons I’m very grateful for having a so called “government controlled” healthcare system.
Unless the drug in question is a particularly strong substance or one that is highly regulated to begin with, all you have to do here is get a doctor’s prescription and pick it up at the pharmacy. If it is a highly regulated substance or very strong, well same thing really, it’s just a transaction that’s a bit more scrutinised.Basically needing a supervisor to sign it out of the pharmacy. Or maybe requiring a second opinion (though even that’s usually rare.)

Like my old step dad has a presription for a particularly strong opioid for pain relief. Only obtainable through a doctor’s constant approval. I think that changed slightly due to COVID restrictions, with doctors being willing to be a little more “lenient” in their renewal options for some stronger substances though lol

 

[danieldemol]

Its crazy to think there are people who go through similar situations to the OP and yet they'll still vote Republican.

Some people never learn.

In my opinion.

 

[Exaltist Ethan]

I have good news.

My pharmacy said the doctor authorized the three-month $7,000 Invega injection I'm getting tomorrow morning. The six-month medication is a much longer process of prior authorization, and is $23,000 for that injection, so I'll have to get the three-month tomorrow and have them work on the six-month in the next three months so I get the longer-lasting medication next time.

The pill form of the medication is like one-fifth the cost of the six-month injection, but is way more uneven in the levels it affects me. I'm not against taking the pill form again if my insurance won't cover the injection, it will, but the injection just works better overall. And the longer the medication lasts the better it is for me.

It takes three weeks after the three months is done for the medication to fully escape my system. So I'm very much still in affect from it. I was a little depressed today, but the news cheered me up a bit.

Given the fact that each day at a psych ward is thousands of dollars, $23,000 every six months is a dime in the bucket. The pharmacists at my pharmacy reminded me to tell my doctor to give PA, prior authorization, for the longer lasting medication. I wrote it down on my dry erase board as something "to do" in the future.

And who knows. Paying that much for this medication now might mean in a few years I'll be able to get a once-a-year injection.

 

[dybmh]

glad to hear it's working itself out, Ethan.