Have you ever had one of those lovely surprises at the pharmacy counter where all of a sudden, your $20 monthly co-pay is $500 and your pharmacist tells you that “your doctor needs to fill out a form?” Let’s talk about that form…
At Birchwood Family Medicine, we explicitly do not work with insurance companies as we find they are almost never working with your best interests in mind. We do however, spend many hours each week advocating for our members, so they get the care they need despite their insurance companies!
Usually when this ^^ scenario happens it’s because insurance prefers you use a different medication than the one your Doctor has prescribed. Or maybe they’ll pay for the medication itself, but in a more limited quantity than what was prescribed. Instead of communicating that to you, or providing any detail about what their issue is, the message is often communicated to you as if your Doctor is the limiting factor.
On behalf of all doctors in America, I can assure you that we are not. The form they require for payment is called a prior authorization, which is both a dangerous & exploitive process. You see – the insurance company’s job is to accept risk for a fee, not to provide medical care. Yet…while simultaneously shifting more of that risk to patients with ever-increasing costs, they are also attempting to influence medical care throughout the United States by requiring prior authorizations (PAs) before paying for medically necessary treatment. It’s not right and it’s precisely one of the reasons we don’t work with insurance.
Instead, we get our members the care they need by investigating whether we can bypass insurance and pay directly for the medication, saving the hoop-jumping for unique situations that aren’t fixed by:
~ educating our members on how to find/use manufacturer or other coupons to bring costs down when directly paying at pharmacies outside of BWFM. Insurance companies have caught on to this and some disallow you from paying directly by threatening to not pay for *any* of your medications if you bypass their system for even one. So…we also fight back by…
~ stocking an in-clinic pharmacy, with access to most medications out there, many of which are less expensive when purchased directly through us – even without a coupon.
~ working with manufacturers to get samples or co-pay cards when we can, especially for expensive branded medications like Emgality, Repatha, Nurtec & more.
~ completing Prior Authorizations (PA) when necessary, a process that can take up to 6 hours per PA. We rarely do them, but find that just like our “go big or go home” approach leads to excellent healthcare outcomes for our members, our typical approach to PA’s generally leads to approval, perhaps because we take the time to remind insurance of the laws & the facts surrounding the scam that this entire process represents.
What you can do to advocate for yourself:
1) Provide a copy of your insurance “formulary” to your doctor so they know which medications your insurance “prefers.” When it won’t negatively affect your care, doctors can preferentially choose one they like to avoid this hassle. For example, this is Forward Health’s (aka Badgercare, Medicaid) current formulary.
2) Choose a Direct Primary Care clinic where cost is always considered and care is delivered for $0.08 on the dollar!
3) Support legislation and lawmakers who fight back against PBMs (Pharmacy Benefit Managers), yet another scam on American patients to line the pockets of Big Pharma & Big Insurance.
4) Have a laugh while educating yourself on how insurance works with pharmacies and why independent pharmacies need our help.
#dpcforlife #themoreyouknow