Long ago I remember chasing an allergist trying to get a medication approved. I would call nearly every week. I didn't understand why the process was taking so long.

Now that I have been a patient managing complex chronic illness for a few years, I've developed a few tips along the way for working with my healthcare team to discuss trying medications and get them approved faster. I use the tips below if I already have an idea of a medication I want to try or if my healthcare provider suggests a medication that is tricky to get approved.

Some things that can assist the process:

• Having a supportive health care provider as an ally to you in the process
• Working with them through shared decision making
• Understanding what diagnosis I am trying to get the medication approved for
  • Find your diagnosis in the DSM, EULAR/ACR guidelines or other medical sources
    • Explore what symptoms from your diagnosis impact you and highlight those in your message or discussion.
    • Is there a diagnosis you have but that is not the primary indication for the drug? For example, there are drugs approved for Excessive Daytime Sleepiness rather than Idiopathic Hypersomnia. Sometimes writing one or the other or missing a diagnosis can throw a wrench in the authorization process
  • Go to the medication leaflet and find its official indications. Discuss these indications with your provider.
• Figure out if the medication you are looking into is approved for an FDA or CMS/Medicaid approved or studied indication for your diagnosis or symptoms. If it has only been studied in clinical trials for your symptoms/diagnosis, provide citations to back up your claims if necessary.

How I would work with the care provider and their team

1. Explain why you would like to use or try a specific medication.
   1. At an appointment, bring up your prior use of this med or why you would like to try this medication out.
      1. If you are trying the medication for the first time:
         1. Are there studies of people with your condition doing well on it?
         2. What symptoms does it treat, what are you hoping to gain from it?
         3. How could it improve your quality of life
            1. consider providing examples of how certain symptoms impacts your activities of daily life
      2. If you have used the medication before:
         1. How has it helped you
         2. What was it used for
         3. Optional: what side effects are there and what is the risk/benefit analysis
2. If you know: how should the provider write the rx for the pharmacy?
   1. For example: the phrase "compounded to be allergen free" works best for my pharmacy. If it is a new medication they usually call or text me and discuss what kind of filler I want for the medication (usually avicel with gelatin or methylcellulose capsule, but sometimes ginger root) and they know to avoid corn starch.
3. Optional: Follow up with MyChart message or phone call to your provider
   Some medications are harder to get approved than others. If I anticipate that a medication may need a prior authorization, I sometimes follow up with a message.
   
   Finding out the 'formula' my providers need to submit prior authorizations has helped me get access to medication faster and with less back and forth.
   
   This gives the team the information they need if it wasn't clearly listed on your chart note or after visit summary.

This information can include:

• medical history, diagnoses
• medical justification for the medication
• relevant ICD-10 code(s)
• citations if necessary

Another format:

• Drug Name
• Diagnosis:
• Symptoms of diagnosis:
• How diagnosis and symptoms impact patient's quality of life, ability to participate in activities of daily life.
• How drug improves symptoms, provides clinical improvement or remission, reduces pain, etc.
• FDA approved indications for drug:
• ICD-10 codes for diagnosis/symptoms:
• Study shown improvements in clinical trials/studies:

Here are some examples:

Example of an abbreviated message typed into in a medication refill request:

Drospirenone (SLYND) 4 mg (28) tablet

• used for prevention of pregnancy
• history of intolerance to o-pill due to heavy menstrual bleeding and ovarian cysts
• contraindication to norethindrone due to (corn) starch in every norethindrone pill and generic
• Slynd does not contain corn in active pills
• Need to avoid estrogen containing contraceptives due to contraindication to combined oral contraceptives due to migraine with aura

Preferred pharmacy: pharmacy name and address

Note: In this example 'used for prevention of pregnancy' is included because that is the only approved use for this medication under medicare guidelines

Example of a MyChart message asking to submit a prior auth for a medication:

Hi Dr. X, I am wondering if we can submit a prior authorization for [name of intra nasal epinephrine]. I have never used epinephrine due to fear of needles. And also, since I'm sensitive to epinephrine, it makes it less likely that I'll use it.

I think these work in my case for PA:

F40.231 – Trypanophobia
Y63.6 – Underdosing and non administration of necessary drug, medicament or biological substance
Z91.128 – Patient's intentional underdosing of medication for unspecified reason
R27.9 – Unspecified lack of coordination (sometimes my arms stop working as well and I lose dexterity/have difficulty with grip)

more info here: [included a link to a guide to prior authorizations]

Thank you!

Example of a provider's prior auth letter to insurance:

Re: First Name Last Name

DOB: 00/00/2000

Drug: [Drug name and dose-

Dear [Pharmacy or insurance]:

This is a letter to appeal the prior authorization denial for patient [First Name Last name].

[First name Last Name] is a 00 year-old [gender] who has been my patient since [date]

They are diagnosed with [diagnosis]. Their symptoms of [diagnosis] include [symptoms]. These symptoms negatively impact their quality of life and ability to participate in activities of daily life, causing [explain how diagnosis impacts their daily life].

Drug name is an FDA-approved medication for the treatment of [diagnosis] that is effective in managing symptoms of [diagnosis] and [symptoms of diagnosis]. When [diagnosis] is managed and treated with [drug], [explain how it will improve quality of life, put patient in remission, etc.].

If drug has been used before, explain clinical and physical signs of improvement such as labs, improvement in ability to participate in daily life, sleep, concentration, nausea or other things.

If drug has not been FDA-approved for this indication, explain how clinical trials show improvement and cite sources.

If drug has not been used before one can explain how the patient would experience harm, their condition would deteriorate without use of this drug/attempt to control symptoms of [diagnosis]

In conclusion, [drug] can provide substantial improvements in [symptoms, participation in activities of daily life, quality of life.] Given their urgent need to address [symptoms], I strongly advocate for the approval of [drug] as medically necessary.

Thank you for your prompt attention and response to this request.

Please call my office at [phone number] if you need any additional information from me. I look forward to receiving your timely response and approval.

Sincerely,

[Provider Name]
[Provider Contact information]

Thanks for reading! This is not medical advice; please be sure to discuss any medication changes or requests with your medical care team.