Mods, please edit this post. Heist, that’s just nasty.
I worked Prior Auth for years. And unfortunately, I dealt with physicians like you for years. You’ve spent so much time on this letter. How about reading their policy documents? Either the compounded med is a plan exclusion, or there will be information contained in the letter telling the family how to appeal the decision. My guess is it’s an exclusion; have the parents take it up with their employer if they’re unhappy with their insurance. Didn’t you have a thread about not keeping electronic records and only seeing patients that pay cash for everything so
Mods, please edit this post. Heist, that’s just nasty. I worked prior auth for years and one of my responsibilities was dealing with physicians just like you. The pharmacist you doxxed is doing his job, enforcing the limitations of the insurance that your patient’s family or their employer paid for. Everyone complains healthcare costs too much; this is how costs are kept down.
You’ve spent so much time on this letter, why not read their plan documents? I expect you’ll find an exclusion for compounded products. If I had to hazard a guess as to why it was previously covered [Note: I’ve been out of the retail and PBM games for years], the pharmacy was billing for straight drug and not a compounded product. Either they complained they weren’t getting reimbursed enough or an excessive quantity triggered an audit (i.e. they billed for 480 ml and the insurer had been paying for 480 tablets).
At any rate, I’d guess we’re talking about a $30-$50 a month charge. Have them find another pharmacy if it’s more than that. Didn’t you say in another thread that you don’t keep electronic records and your patients’ parents are all cash payers so Big Brother can’t see what meds they’re taking? Alternatively, use a commercially available product. I’d be happy to help if you’d like some suggestions…other than the aforementioned clonidine patch. Comes on so slow there’s no post dose lethargy.