Opinion | PBM Called for a Prior Authorization? That’s News to Me!

Early Saturday morning, my home landline started ringing and the scary mechanical voice that translates caller ID told me it was my pharmacy benefits manager calling.

I picked up the phone, and a polite electronic voice told me that they were unable to ship one of my medicines to me since they had been unable to reach the prescribing physician to get prior authorization.

The interesting part here is that I’m actually the prescribing physician. I know, I know, we’re not supposed to prescribe our own medications. It’s apparently both some sort of HIPAA violation and a security violation when we enter our own charts.

For a couple of my chronic medications, I admit that instead of reaching out to my specialist’s office, I will often click on a refill request in the patient portal, which sends it over to my own refill encounter in-basket, where I then approve it.

To be honest, I don’t think this is abusing the system that much. These medications are the same ones I’ve been on for many years, and it has always just seemed easier than bothering the docs who are managing this condition for me.

I have yet to figure out why we’re not allowed to enter our own charts. I’m not sure what in there they don’t want us to see, especially since now with Open Notes I’m able to see everything everybody writes about me (malodorous, unkempt, noncompliant, belligerent white male in no acute distress). Whoever created this rule that we can’t be in our own charts should probably do a better job of explaining to us why.

The day before that phone call to my home number, I had refilled two of my chronic medications, which the insurance company has been filling for the past few years without issue, but apparently one of them had suddenly become non-formulary for my insurance plan.

If this medicine now requires prior authorization, I would be happy to take care of it, since I did not in fact tolerate either of the alternatives they suggested.

Interestingly, when I went into the chart to try and figure out what had happened, I saw that they had in fact sent a request for one of the alternatives, which I had not tolerated in the past.

How did they get to decide that that was okay?

After this disembodied voice on the phone told me that one of my medicines was being held up, I tried to go down their voicemail chain to speak to a human being. I wanted to ask somebody, how had they been unable to reach the prescribing physician, when in fact that was me, and no one had tried to reach me?

There was no mention of a phone call in my chart, there was nothing on my office voicemail, no fax, no one had reached out to my cell phone, no denial was noted anywhere in my electronic medical record.

If I’d been able to get to an individual with a pulse on the phone, I would’ve quickly been able to tell them that no, they had not reached out to my prescribing doctor, since that was me, and then I could’ve told them the reasons why I needed to stay on their non-formulary medication, due to drug-drug interactions and past intolerance of one of their suggested alternatives.

I guess this is an unfair advantage I have, that we all have, when we play doctor and take care of ourselves when we should be allowing someone else to do all this for us.

Many years ago, knowing that many of my partners here in our practice (like so many busy doctors) were not getting some of the routine healthcare we all should, blaming it all on our busy lives, I tried to set up a cross-institutional primary care physician (PCP) switch with one of our other local academic medical centers.

Collaborating with the medical director of this other practice, we volunteered to set up all of our providers who didn’t have a PCP with one at the other site, and vice versa. We got no takers. You can drag a physician to primary care, but you can’t make them drink the water.

So yes, I’m skirting around the edges when I self-prescribe some of my medications, I really should follow the rules and let my specialist take care of this.

But I would hope that regardless of who the prescriber was, this mail-order pharmacy system, run by a large pharmacy benefits manager, would actually reach out to the prescribing physician before calling the patient and telling them that their doctor refuses to get back to them with answers to their questions.

I happen to know this patient, he’s one of my favorite people, why would I not call them back, I want him to have his medicines, I want to help him be compliant.

So now we’ll just have to wait and see what the week holds, how we’re going to be able to reactivate the process of getting prior authorization for this medication. I’m willing to go through whatever administrative hoops we need to get this done.

Don’t get me wrong, pharmacists are such an incredible and necessary part of our healthcare teams, both on the inpatient services and in the outpatient setting, those that work with us at our practice and those in the community doing the incredibly challenging work of helping take care of our patients.

They have proved invaluable in helping us dose-escalate medications for patients, helped improve compliance and education, catch medical errors, and in many cases become such an integral part of the team that the patients reach out to them before they even call us.

But this phone tree that wouldn’t let me get through to a live human being, and ultimately disconnected me, really didn’t provide much help.

It only told me that they’d called Dr. Pelzman to get some information and that he refused to respond.

Well, here’s my response.