Thread by @NeuCare

I know nobody needs another story about how insane health insurance plans are, but I have a story + GIFs for ya...

About 2 months ago, I received a prior-auth request on a patient for gout medication called Urloric.

Backstory: Jimmy is a 30-something y.o. guy w/ bad gout.

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For many years he tried to manage with lifestyle. Despite doing great there (normal weight, eats healthy, improved fitness), he still had high Uric Acid & gets frequent, terrible flare-ups requiring anti-inflammatories & colchicine.

He has bad genes.

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So, after many years of just treating attacks--crippling him for days each-- he reluctantly agreed to a daily preventive med called allopurinol.

As luck would have it, he was the rare person who got a bad reaction; developed flu-like symptoms within a week that could be...

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...a sign of severe/life-threating allergy. He stopped the med, of course!

Luckily for him, there is another med, Urolic, that has a similar effect/benefit but less likely to cause this allergy. Unfortunately, at that time (about 4 years ago), Uloric was available only...

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....as a brand-name and quite expensive ($300-ish/mo. full price). We jumped through a few hoops and he got it approved by the plan.

He's done great since then--normal uric acid & very few, if any, serious gout attacks. The Uloric has been somewhat expensive, but...

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...he has found coupons that have reduced out-of-pocket costs for him.

Fast forward to 2019: Uloric has now gone generic....YAYYY! Several manufacturers are making it and pricing coming down to near $100/mo; not cheap but 1/3 the brand!

Back to the prior-auth:

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Jimmy apparently switched insurance plans ($1200/mo for family) in 2019 which doesn't know his history. So, the first refill of Uloric, they want justification for why he needs it; fair enough.

The plan suggests using a website for a "streamlined" online PA.

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The webpage, once loaded, just says "denied" -- no ability to edit or submit any response.

So, my nurse calls the phone number & after 20 min. hold is told THEY don't process this. They now using a third-party (? PBM) for approvals. A different phone number is given.

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After another long phone hold, they fax us a form to complete. We report his history of gout & reaction to allopurinol & good response to Uloric.

They do ask has he taken any other meds, including colchicine, for prevention?

(pharmacology weeds upcoming, but important)

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Jimmy HAS previously taken colchicine for flares (somewhat helpful) & for a few months while starting Allopurinol & Uloric. Historically, this med was used for prevention by itself. But, for many years nearly every expert/guideline says...

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...it's NOT a good choice long-term compared uric acid lowering meds like Allopurinol or Uloric; it shouldn't be used by itself in most patients!!!

onlinelibrary.wiley.com/doi/full/10.10…

Another med (Probenecid) is an even worse choice for prevention.

That's the whole list!

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So, I'm feeling pretty good about this getting approved because, really, what is the other choice here?

Within about a week, we get a response: DENIED!

Approval of Uloric requires the patient must first "fail" two other preventive meds, suggesting colchicine instead.

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I know what you are probably thinking..."Insurance plan doesn't want to pay for the more expensive med"

Not so fast...

Colchicine, although a very old med, skyrocketed in price several years ago due to some complex FDA stuff: mdmag.com/medical-news/w…

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There are a few options now (1 generic) but the plan suggested brand "Mitigare" @ $120/mo. (subject to approval of course! I'm not kidding)

Remember, Uloric is now generic & $100/mo. (a plan was previously paying 3x for this med!)

So, clearly this...

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...is NOT about forcing a patient to take a cheaper med!

But why? It is very possible--speculation here-- there is some type of PBM "rebate" (aka. kickback) at play here. I've written about previously: threadreaderapp.com/thread/1128855…

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After screaming a few times, we wrote a letter to explain why colchicine is not a good choice & desire to continue Uloric. But, again...DENIED!

At this point, I request a "provider-to-provider" call because the algorithm isn't working. (or is it?)

The PBM tells us...

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...they don't do "clinical" reviews in-house. They rely on a different company (medical consultants?) for that. (that's the 3rd third-party if keeping track).

They give us another phone number (only). We call it. They send us a form. (You know the routine!)

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It's basically the same med history form as the initial! We dutifully fill it out (again) and fax it back.

Within a week or so...DENIED!

(After cooling off for a few days) We call again to request a provider-to-provider call but told by fax...

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"This case is closed and beyond the 7-day window to appeal. It was reviewed by a (nameless) board-certified Rheumatologist."

The fax educated me by providing a list of articles about gout management. Although I know this info well, I reviewed them. Some excerpts...

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"American College of Rheumatology and European League Against Rheumatism guidelines recommend uric acid-lowering therapy (Allopurinol or Uloric!) until serum uric acid is maintained at ≤6 mg/dl."

COLCHICINE DOESN'T DO THIS!!!

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Now I'm fightin' mad, so call to request the name & license number of the physician who reviewed the case.

Predictably a rep tells me, "I'm sorry, sir, we cannot provide that information. Our physicians are anonymous."

Me: "Is there any recourse here?"

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"We suggest you talk w/ the insurance plan".

[CLICK]

So, Jimmy and I are obviously not happy. Despite spending enormous time & effort, I feel like I failed.

Could I have used better/different/more words to get my patients what they needed? I dunno. Maybe.

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Jimmy will have to decide to pay for Uloric (luckily cheaper now), or do a trial of another medication which isn't ideal--or cheaper!--by any standard of care.

I don't know what he will do, but that's the story.

Next patient.

/done

Added comments based on feedback:

Frankly, I am a bit afraid to name the ins. co. or PBM publicly. As you can see, they already have tremendous power to make my patients’ (via my recommendations!) life a living hell.

I suspect I’d end up on a “bad doctor” list quickly!

I’ve also been advised by a few attorneys—not my first rodeo de ranting....haha—to not share such details. Even it’s all 100% accurate, a lawsuit is not something I can afford. (They can!)

If wanting to deal with yet more bureaucracy, we could report this companies to state insurance commissioner. But I very much doubt they’d get involved in this case—nothing illegal or fraudulent here.

And, they certainly won’t put the screws to a VERY large health plan!

Jimmy will get the med; he can thankfully afford it at $100/mo. But calculating the amount of time = money spent on this nationwide, everyday is almost incalculable.

But it’s all “covered” & part of the “plan”, so....