I can’t believe the hurdles my insurance puts me through in order to approve my medication (Oregon) (PacificSource)

I received a denial for PA for Mounjaro, which I use for t2d. Now, I completely understand that this is a pretty expensive and relatively new medication, and I am familiar with the prior auth process and typical requirements to be approved for medication. In fact, I don’t mind an insurance company wanting to utilize their financial resources appropriately. But my insurance requires me to use 13 oral medications, and 4 injectable medications that each require a prior auth before they will approve Mounjaro. If I didn’t need to go through the hassle, and found a previous medication that helped me I would not be going through this, but I have tried one oral and three injectable medications before this.

I don’t believe they are setting me up to have anything other than my time wasted buried in the prior auth / denial circus, so I have resorted to going public and confronting them on social media. At this point I think it’s time for the insurance companies to feel pressure to provide adequate coverage to GLP-1 medications.

Link to twitter post

This is what I posted on FB:

PacificSource: I received a determination on my prior authorization for a long-term medication that I have been taking since qualifying for my employer provided plan and it was so appalling that I feel the need to publicly discuss the low quality of your health plan. The determination made by your company states that I need to take EVERY SINGLE MEDICATION on your formulary before I am able to continue taking the medication that has finally addressed my health issues. There are 13 medications on the formulary list related to my diagnosis with an additional 4 medications which each require a PA before I can be approved for the medicine that I am currently taking, tolerating, and have better results than I have ever had.

In order to adequately evaluate the efficacy of each medication, a blood test measuring three months of my blood sugars (a1c) is necessary, which means I would need to stay on each medication for a minimum of three months to measure long-term results. Doing the math, I would have 37 months of potential failed medical therapy and an additional 12 months of medications requiring PA which delays care every time a PA is needed. So in total, I would be subjected to AT LEAST 4 YEARS of trialing medication before finally being able to use the medication I am currently using.

There is no medical standard in this country that would compel a medical provider to actually subject a patient to 13 new medications before they resort to the medication that is working to address their condition. This process adds additional labs draws, doctor’s visits, potential adverse reactions and exposure to serious side effects that far exceeds what is necessary to determine an appropriate therapy. This is, by definition, a delay in care and has no basis in evidence based practice.

Additionally, in the current climate of healthcare shortages, I have struggled to find a PCP that will accept a new patient. I am currently waiting until May to possibly – POSSIBLY – be seen as a new patient, but the PCP office says it’s more than likely going to be June before they can get me into their office. It would be to everyone’s benefit to provide the care that is proven to work and avoid the excess utilization of healthcare services that are clearly not available in these trying times.

Lastly, PacificSource requirements for prior authorization are poor-quality and do not even remotely approach the standards of similar insurance companies that require PAs for this medication. This determination risks the possibility of my being injured by the unnecessary gamble that 13 new medication trials would subject me to. An appropriately minded provider would limit so much exposure to risk and I am extremely disappointed in the medical professionals employed by PacificSource who were involved in such a poor determination.

In closing, I am deeply disappointed by the lack of quality your company demonstrates. I do not deserve to be subjected to so much unnecessary risk. I pay my dues and expect to have a reasonable level of coverage by my health insurance company. I am publicly disclosing this determination to alert others enrolled in my health plan of this concerning lapse in judgement. My coworkers do not deserve to pay into a plan that would treat them in an equally negligent manner, and our community should not have access further restricted. I will meet you at every step of every unrealistic hurdle your company uses to restrict my access to appropriate health care (both internally through PacificSource channels and external advocacy resources) and I will provide my honest feedback to my employer and urge them to find another healthcare plan that does not risk the health of the employees they rely on to provide essential services to our community. What am I paying for if not access to care? What is my employer paying for if not a healthy workforce?