Back in third grade, though I was the most advanced reader in the class, I was the only one still unable to tie his own shoelaces.
A couple times a month I still misbutton my shirt, usually without noticing. I am not mechanically inclined.
The three words I dread most have always been, “Some assembly required.” That practically guarantees I’ll be incapable of assembling the device and have to ask or hire others to do so for me.
But this year I found three words I dread even more: “Prior authorization required.”
I’ve been hearing it a lot lately. It started when I began 2025 with a different health insurer. The new provider has done a good job overall, giving me much better coverage than the prior provider — with one exception.
There’s a certain medicine I take to improve my breathing. Started taking it in July. It’s temperature sensitive, must be shipped in special cold-retaining boxes, and must be refrigerated upon my receiving it.
Possibly because of the temperature sensitivity, I must get this medicine from a specialty mail-order pharmacy. Both the old insurer and the new insurer agree on that.
But in 2025 I have not received a single dose of this medicine.
I followed all the rules. At the end of 2024 I informed my pulmonologist’s office about the change in insurers. In early 2025 I informed a financial-assistance company that kindly pays for the bulk of the medicine’s costs.
But somehow, I keep slipping between the cracks.
The medicine gets injected. I’m not confident I can use a syringe properly. So, I opted for an auto-injector pen, which one places against one’s skin and then depresses the plunger. That much I can do.
But I haven’t received the medicine in 2025.
I’ve squandered many hours over the phone in quest of the reason for my inability to receive the medicine. I’m always told “Prior authorization required.”
My typical response: “Authorization from whom?”
The answer keeps changing.
The insurance company says I need authorization from my doctor. My doctor says I need authorization from my insurance company. The specialty pharmacy sometimes says I need authorization from the insurance company, but sometimes says I need authorization from my doctor.
In the meantime, I’m sitting at the table with my phone, holding a written authorization the insurance company mailed me in early January.
The mail-order pharmacy doesn’t care what written authorization I have in front of me. They’re not allowed to take my word for anything.
At one point I had all three forces — doctor’s office, insurance company, specialty pharmacy — in agreement that I should get the medicine.
But then a fourth player stepped forward. They’re called a pharmaceutical benefits manager (PBM). They too are somehow on board the health care train and have authority to pull the emergency brake and bring drug delivery to a halt whenever they decree.
The existence of the PBM surprised me. So, I phoned them up but, they told me, they are not allowed to communicate with mere patients. They wouldn’t discuss the matter with me. The woman wouldn’t even give me her surname.
So, some anonymous, shadowy entity can pull the brakes on any individual’s drug treatment.
That’s our wonderful health care system.
Because everyone uses computers, medicine names no longer matter. Instead, these companies deal with code numbers assigned to each medicine.
At one point, the code number used by the insurer was one digit off from the code number used by the specialty pharmacy. Which meant I could get the medicine in syringe form, if I wanted (I didn’t want), but not as an injectable pen.
Oh, about two weeks ago I did receive a package from the specialty pharmacy. It contained a bag of alcohol swabs. Nothing more, nothing less.
The swabs are used to sanitize the injection site before administering the medicine. Unable to send the medicine, they sent the swabs instead.
That made me mad.
It’s as if a pizza parlor that has been trying to get you approved to buy a pizza gives up but nevertheless dispatches a delivery vehicle to send you the paper napkins that normally come with a pizza pie. As if they’re taunting you.
Ridiculous. But true.
Over the weekend I was at the wonderful Sugar River Pharmacy in Newport, where I get all the family medicines that don’t have to come from a specialty pharmacy. I asked a pharmacist there to explain from whom I need to get prior authorization. She gave the best answer I’ve heard yet.
Prior authorization, she said, is a hopelessly complicated communication between the doctor’s office and the insurance company.
“And then,” I asked, “the insurance company notifies the pharmacy that authorization has been granted?”
“Not always. They don’t have to. So, some don’t.”
I believe her.
Sigh. Less than 1,000 days now until I’m on Medicare.
Maybe that system works better.
