Insurance Red Tape Blocks Crucial MS Medication

Jaclyn Mayo, a Massachusetts resident with multiple sclerosis, experienced a significant disruption in her care when her prior authorization for the GLP-1 medication Zepbound expired. This drug had substantially improved her MS symptoms, including balance, sleep, and numbness in her hands, by reducing the stress on her joints. After seven months on the medication, her pharmacy refused to refill her prescription due to the expired authorization.

Navigating the insurance system, Mayo discovered that her prior approval had lapsed. Her doctor had to resubmit paperwork, a process that would take seven to ten business days, leaving Mayo without her medication for two weeks. During this period, her symptoms resurfaced. While insurers like AHIP state prior authorizations ensure safe and affordable care, patient advocacy groups, such as the American Medical Association, criticize the process as opaque and burdensome.

Experts note that expensive medications like GLP-1s face greater scrutiny. The process for obtaining prior authorization can be lengthy and complex, with varying policies across different insurance plans. The American Medical Association reports that one in three insured adults considers prior authorizations a major burden.

Navigating these hurdles often involves understanding that insurers may have different approval timelines. Patients are advised to inquire about their specific prior authorization durations and to factor potential delays into their treatment plans. In urgent cases, doctors can request expedited reviews, although insurers do not always readily offer this option. Federal regulations now require decisions on urgent requests for employer-based plans and Medicare/Medicaid within 72 hours, though this doesn't always apply to medications.

If a prior authorization is denied, patients are encouraged to appeal. Research indicates that patients win about half of their appeals, especially when providing comprehensive documentation of previous failed treatments. Exploring alternative medications listed on the health plan's formulary may also be a viable strategy, although formularies can change. Ultimately, the prior authorization system presents a significant administrative challenge for patients seeking necessary medical care.