r/Insurance • u/Original-Software690 • Jun 24 '26
Health Insurance Pediatrician cannot prescribe Albuterol for asthma without a prior authorization.
I am a livid pediatrician - 13 years practicing - never have i seen such a dangerous abuse of power than i did today.
I saw a kiddo with Kaiser Options insurance... He was having difficulty breathing and a cough... After breaking his asthma attack in the clinic with albuterol and a steroid. I sent the child home to pick up more albuterol and a steroid to continue treatment.
The standard therapy for albuterol for an asthma exacerbation is 4 puffs every 4 hours while awake and an oral steroid...
Got a call that the albuterol requires a prior authorization....
This child could literally die today without this medicine... You have 1 airway... What if i fill out this form wrong or the person who reviews them checks their email in 2 days.
I have no idea what else i can do. What an astonishingly dangerous abuse of power and stupid move...
I am so angry and feel powerless...
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u/headgoboomboom Jun 24 '26
This is getting more and more out of hand. We seriously need to say NO.
I have a migraine patient who switched insurance. The new company is demanding she try a medication that she already failed. Infuriating... š¤Æ
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u/Kindly-Ad2656 Jun 25 '26
When you submit the prior authorization to the new insurance, submit the previous insurance approval, and the documentation you sent with that prior authorization. And then call and argue.
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u/OkMiddle4948 Jun 24 '26
And all you need to do is submit documentation that it was already tried and failed. How are they supposed to know this?
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u/Clean_Philosophy5098 Jun 24 '26
Who TF cares. The Dr. prescribed a medicine, they are the professionals. The insurance company needs to pay it.
I work in insurance (not health) and it has no business being involved in medical care. It adds a layer of bureaucracy and exists to skim profit.
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u/Jaezma Jun 24 '26
I am also in insurance and am deeply passionate about my job and I agree 100% that health insurance has no business being able to make treatment decisions.
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u/headgoboomboom Jun 27 '26
What do you think that I did?
The real issue is that we are forced to do this in the 1st place. We really should grow some testicles and actually stop doing all preauths for anything.
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u/Choice-Education7650 Jun 24 '26
My husbands insurance denied his blood thinner script and surprise, he got another blood clot and more surgery. Some insurance clerk should not be able to override a doctor.
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u/Kindly-Ad2656 Jun 25 '26
Check prices on Mark Cuban. There is a generic blood thinner on there that is around $30 a month.
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u/Impressive-Peak-6596 Jun 24 '26
American Healthcare, scratch that, almost every American business has become a bare bones, corporate hellscape.
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u/InternetDad Jun 24 '26
I suggest finding a medical professional related sub, or even try r/healthinsurance. I haven't seen anyone post here with the clinical expertise to guide you. The most I can suggest is what about an alternative
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u/Original-Software690 Jun 24 '26
Thanks just found the nearest sub to vent - maybe no guide needed I've found a way to get the kiddo what he needs....
Just was so angry that i felt the need to shout into the void... Thanks for being the void.
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u/CatmoCatmo Jun 24 '26
If you donāt mind me asking, what were you able to figure out for the little guy?
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u/Original-Software690 Jun 24 '26
Changed to nebulizer - nebulizer takes 20 mins to deliver the med, (toddlers love to wear the mask and sit still for the 20 mins /s) requires tubing a machine and education on how to use it...
Not beat practice but acceptable
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u/Magentacabinet Jun 24 '26
Poor guy, I hope he feels better soon.
I hate that you were having such an issue trying to get him the medication that he needed.
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u/Provia100F Jun 24 '26
Did you try bedrest and ibuprofen? Let's try a round of antibiotics before we authorize albuterol. - Insurance, probably
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Jun 24 '26
[removed] ā view removed comment
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u/rikityrokityree Jun 25 '26
Goodrx.com is a great tool for pricing drugs from area pharmacies with out using insurance.
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u/ohbeep Jun 24 '26 edited Jun 24 '26
Which albuterol did you write for? Proventil should be covered. I dont see any insurance not covering albuterol. But depending how the prescription was written/ how the pharmacy put it in, it might be why it came up as needing a prior authorization. As another comment mentioned, there are alternatives and a PA shouldn't be complicated if you have the documentation and can read/follow directions for filling it out.
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u/Original-Software690 Jun 24 '26
Proventil after speaking to the pharmacist apperantly anything more than 2 puffs every 4 hours is overuse and requires a prior auth
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u/Actual-Government96 Jun 24 '26
apperantly anything more than 2 puffs every 4 hours is overuse
Apparently? You mean per FDA guidelines.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020503s046lbl.pdf
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u/ohbeep Jun 25 '26
Ahh that makes sense. In that case Id suggest writing as 2 puffs q4h PRN so they can get the med at least. and then give the parents the directions for when patient has an acute exacerbation. Insurance is gonna assume youre writing for a continuous therapy and sees that as a no no.
Hope it all worked out (insurance sucks)
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u/Separate_Respect1720 Jun 24 '26
Where did you get 4 puffs every 4 hours from ?
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u/inertial-observer Jun 24 '26
Not a Dr, just an asthma patient. That's essentially the same dose you get with a nebulizer. I'm not sure why those aren't used more, seems to work a lot better than just the inhaler I think. Anyway. 4 puffs is the higher dose to help during an attack or exacerbation.
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u/ohbeep Jun 25 '26
I think nebulizers are still used too. And are probably better for sure. But the inhalers do make it convenient for portability sake
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u/Separate_Respect1720 Jun 24 '26
Ok things have changed then, Iām a 62 year old asthma patient and my albuterol dosage has always been 2 puffs every 4-6 hours during exacerbation.
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u/pementomento Jun 24 '26
Well, itās Kaiser, not surprised
But is the pharmacy submitting with an aggressive day supply number with that dose frequency? It might be auto denying based on days supply.
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u/MD_reborn Jun 25 '26
You probably wrote a brand name and not "albuterol". If so, that may have triggered the prior auth.
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u/Kindly-Ad2656 Jun 25 '26
The pharmacy is probably billing the wrong day supply or theyāre filling brand when they should be filling generic, or vice versa.
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u/s0methingggg Jun 24 '26
Well itās Kaiser, literally one of the shittiest insurance companies on earth and yet consumers every day are absolutely obsessed with them, then dumbfounded when their kids donāt get life saving inhalers
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u/DJD19500 Jun 29 '26
Iāve never heard Kaiser described as an insurance company. Itās an HMO with a huge range of services. I have beefs with them but they do have some outstanding employees, including the ones who did my OH surgery and the coagulation team which follows me closely.
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u/OkMiddle4948 Jun 24 '26
No way you are a pediatrician.
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u/Original-Software690 Jun 24 '26
I am...
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u/Dismal-Rich Jun 24 '26
Give nebulized albuterol to hold them over. And check if the pharmacy is billing for 17-18 days. Sometimes they push back if itās calculated as around the clock
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u/Dismal-Rich Jun 24 '26
Also nebulized solution is cheap even if they have to pay OOP - use good rx or a similar savings card
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u/OkMiddle4948 Jun 24 '26
Yet youāve never seen a PA for Albuterol in 13 years, donāt know how to submit a PA electronically or a worried you might check the wrong box, didnāt check to see if an alternative might be covered etc?
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u/ImHufflePuff_Crap_ok Jun 24 '26
Guessing you havenāt seen the endless amounts of videos where doctors are record themselves arguing with insurance after a failed PA because the insurance is checking boxes?
Weird, what wormhole is that?
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u/OkMiddle4948 Jun 24 '26
Yes, I have seen videos of doctors chasing clout complaining about insurance practices or feigning ignorance of standard policies that have been in place for over a decade or more. Surely someone with a medical degree can figure out which box to check right?
My point being again 1) thereās no way this is the first time you saw this in 13 years as a pediatrician. 2) there are other options available besides fear mongering on Reddit that your āpatientā is going to die.
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u/Rumpelteazer45 Jun 24 '26
Found the United Health Insurance person!!
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u/OkMiddle4948 Jun 24 '26
This is a Kaiser post genius. At least pick the right insurance company,
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u/Magentacabinet Jun 24 '26
This shows that you know nothing. Formulary changes happen all the time. Drug companies literally negotiate with insurance companies to have their drugs covered or not covered. Go back to your hole.
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u/OkMiddle4948 Jun 24 '26
What does that have to do with anything? You think formulations are secret?
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u/TheHykos P&C Compliance Jun 24 '26
Albuterol has been around for over 50 years. It's relatively cheap and has several generics and is the standard treatment for asthma. It should never require a PA. Also, to my knowledge as someone with asthma for 30+ years, there is no alternative.
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u/wistah978 Jun 24 '26
I was agog until I saw the word Kaiser.
Admit the poor kid.