Denied Rx prior authorizations? Call your congressman

In the middle: Patients

Doctors battle increasingly high hurdles as insurance companies' efforts to control costs put restrictions on prescription drugs -- even those used to treat common maladies

Boston Globe, June 25, 2006

By Christopher Rowland, Globe Staff

The stabbing pains struck her left leg, shot up her hip, and flared into her back. They became so severe that Patricia Rodrigues, who has a rare genetic disorder called mitochondrial myopathy, sometimes screamed in agony.

She could not get out of bed into her wheelchair, never mind drive her minivan equipped with hand controls. Twice in recent weeks her daytime care assistant became so alarmed that she had Rodrigues taken by ambulance to a hospital emergency room.

Worst of all, her intense suffering could have been prevented. Rodrigues's doctor said her insurance company covered the cost of pain pills, which were ineffective, but denied his request to give her a $40 skin patch filled with a powerful narcotic called fentanyl.

``I felt horrible. I really felt helpless," said Dr. David Judge of Bulfinch Medical Group at Massachusetts General Hospital . ``I was stonewalled by the company."

Rodrigues, 59, suffered for five weeks while Judge and his office staff battled with WellCare Health Plans Inc., a for-profit insurance company in Tampa, Fla., that provides her prescription drug coverage under the new Medicare Part D benefit. Her previous insurance plan allowed the skin patch.

Her case is a dramatic example of how insurance company restrictions on prescription drug coverage can affect patients. Many doctors say they are facing increasingly high hurdles in their attempts to prescribe drugs, even those that treat common maladies like heartburn and migraine headaches.

Earlier this month , a Framingham physician, Dr. Stephen A. Hoffmann , told the Boston Globe that he violated state prescribing regulations to circumvent insurance rules and obtain essential medications for some patients. The state attorney general's office and the Board of Registration in Medicine this week would not comment on Hoffmann, but doctors and others in the healthcare industry said his actions are not typical -- like Judge, most physicians adhere to the rules, despite mounting frustration with a system focused on curtailing rising drug costs.

Insurance companies say formularies -- limited lists of medications they will cover -- have been a key part of efforts to control spending. According to insurance industry figures, the lists have helped slow the rate of growth in drug spending from 15 percent in past years to 8.6 percent in 2005. Their use also is supported by many public officials and employers.

Under formularies, drug companies may only cover one or two treatments for a particular ailment. They also may limit the amount of medication allowed monthly. Special permission, called ``prior authorization," is available for some drugs that are not included as part of a formulary.

But doctors and patients say winning prior authorization is complicated and time-consuming.

Eli Medwar , a retired Sharon accountant, said that when his prescription for the reflux disease medication Protonix was reduced from two pills to one pill a day by Blue MedicareRx, a national Medicare prescription plan , he suffered heartburn. After his doctor's appeals to the insurer were denied, Medwar complained to his congressman, Representative Barney Frank , whose office contacted Blue MedicareRx and was able to secure Medwar's twice-daily dose.

In another case, a group of area psychiatrists recently complained to Blue Cross and Blue Shield of Massachusetts about restrictions on brand-name antidepressants . If a patient doesn't respond to generic drugs, special permission must be sought from the insurer to prescribe more expensive brand-name medications, according to the doctors.

``There is a serious delay in care because of this," said Dr. Eileen Kahan, a Lexington psychiatrist who was part of the group. ``Since we often see seriously ill people with severe depression often accompanied by suicidal ideation, this is a significant problem."

Blue Cross and Blue Shield of Massachusetts spokesman Chris Murphy said the insurance company takes no more than two days to review prior authorization requests. If doctors have a more urgent demand for a review, there is a special phone line for expedited services, he said.

In the case of Rodrigues, Judge said he was unable to contact by phone anyone at WellCare with the authority to reverse the rejection of the pain-relief patch. Appeals sent by fax were denied several times, he said.

WellCare spokeswoman Kristen Petrillo said the company is prohibited from even confirming whether someone is covered by one of its plans. But the fentanyl-filled pain patch Judge wanted for Rodrigues is not covered by WellCare's Medicare Part D plan, Petrillo said.

The company's Part D drug list ``includes several therapeutic alternatives for fentanyl, but not fentanyl itself," she said. ``If a member is prescribed a drug that is not on our formulary, we will suggest an alternative." Approved alternatives for fentanyl include morphine and hydromorphone, she said.

Judge said Rodrigues was taking the powerful pain reliever oxycodone, but her compromised digestive system was unable to adequately absorb it.

``I'm suffering because of the insurance company," Rodrigues said last Tuesday at her home in Southeastern Massachusetts, moments after she applied her first patch in over a month. When the pain is at its worst, she said, ``I would just cut this leg off if I could."

While state health policy advocates say preferred drug lists help control costs and make healthcare more affordable, they acknowledge that they are cumbersome.

``It's a two-edged sword," said John McDonough , executive director of Health Care for All , a Massachusetts nonprofit organization that lobbies for healthcare reforms. ``On the one hand, there has been a significant taming of the rate of increase of drug costs. At the same time, it is important that it be done in a way that doesn't discourage people from getting the necessary care they need,"

``Sometimes it can get pretty messy," McDonough said.

Dr. Kenneth R. Peelle, president of the Massachusetts Medical Society, which represents doctors, said some checks on prescribing may be appropriate, but they are not standardized and are too complicated.

The Massachusetts Association of Health Plans has published a pocket guide to the drug lists used by the state's major insurance carriers. It believes formularies, which impose larger co-payments for brand-name drugs and lower ones for generics, are an effective way to cut costs, said the association's president, Dr. Marylou Buyse .

At Judge's medical practice at the Bulfinch Medical Group at Mass. General, 22 doctors, four nurse practitioners, and 22 residents write 800 to 1,000 prescriptions a week, said Marcy Bergeron, one of the nurse practitioners.

A year ago, the office handled about 20 prior authorization applications weekly. That's up to about 32 a week this year, Bergeron said. Each requires repeated phone calls and faxes -- and plenty of patience, she said. A process that once took 72 hours now often takes eight to 10 days.

``This is not helping us with cost-consciousness," she said. ``This is making us frustrated."

Christopher Rowland can be reached at crowland@globe.com.