Prior auth requests for a "non formulary" drug is the biggest scam the insurance company has screwed us with!!! On 10-29-15 my son's doctor sent a PA to Optum for an approval on Accutane that my son is currently on. It was denied due to Not Medically Necessary!!! (he has been on it for three months already and need to be on it another 3 months.) and the fact that they have been paying for the drugs but his PA date had expired. There is already a PA in place for him… Just extend the end date. After a few more days, Doctor's office called to see why PA was denied… Was told they didn't have enough information to auth it. Next day, nurse called with all the clinical info needed to see if it would get the approval, but the drug was denied again!!!
Now I had to get involved… Within a minute I found out what had happened! All the clinical info given for my son was put under my husband who is 50 and doesn't see the doctor for acne… Or is taking Accutane!!! At this point I realized I was talking to a bunch of incompetent asses and demanded a supervisor… Surprise… They do not have a Supervisor at this time that can speak to me! So I started my ranting: "Who looked at the PA for approval? What qualification did that person have? Why was the info put on my husband file and not my son's? Who is taking responsibility for this???"
DO YOU KNOW WHAT HER ANSWER WAS???"Due to HIPPA regulation I can NOT discuss this matter with you, I can only speak to the patient." OMG if they think I'm going to let this go they are sadly mistaken. Denying a drug that is critical to a patient's need is a tragic mistake. Optum Health should have known about. It's their problem to deal with when they have law suits on their hand. Patients having to suffer. Due to the fact that Optum Health hired idiots to take clinical info and processing them.