On Point submissions are individual member viewpoints and not North Carolina Medical Society policy.


Arthur E. Apolinario, MD, MPH, FAAFP, CH

Here is what prior authorization means to physicians.

I am a suboxone MAT provider. I get people off heroin and opiate addiction using office-based therapy.

Today I have a patient in trouble.

She is 21 years old, doing well after 2 years on therapy, and pregnant. I have to make a decision for her.

She must come off suboxone and go on buprenorphine immediately to prevent NOWS in the baby or it will suffer withdrawal syndrome. If she goes without the medication altogether, she can go into immediate withdrawal and lose the baby.

I can protect her, but my hands are tied. The Medicaid managed care company will not fill the correct medication without prior authorization.

I referred her to the UNC High Risk Pregnancy Clinic and changed her medication immediately. That wasn’t allowed. We sent records proving she was in a very dangerous situation and she was denied again. At this point she had not taken the new medication and we are in the second day of trying to protect her and her baby. When a pregnant woman withdraws from opiates she may miscarry.

My nurse spent four hours, half a day, working on this by making phone calls. I told her I needed a medical director on the phone to review the records and get this medicine expedited. Finally, it was approved.

It took another several hours to find a pharmacy that had the medicine. Thankfully, through hours and hours of unnecessary work, she had the medicine in her hands.

If that had taken longer, her next choice would be to return to the streets and buy street drugs again.

That is what prior authorization creates for physicians.