Androgens and Anabolic Steroids Prior Authorization Criteria

This is a document from Blue Cross Blue Shield that I found very interesting:

Androgens and Anabolic Steroids Prior Authorization Criteria

I noted that it has a copyright date of 2010; any idea of there is a more recent version, or is this still controlling?

I have Federal BC/BS and it looks like ALL the test products require prior approval. Attached are latest forms that are required to get prior approval for injectable test.

BTW I have BPH and have tried all the expensive meds and the only thing that works for me is Cialis.... I end up getting up 3 or 4 times a night to pee I need prior approval and will turn in the forms to my DR on Monday and see if he can fill out his part and send in.... Will see..... My other option is off shore

This is becoming more common with all the insurance carriers as they strive to NOT cover as much or your medicine as they possibly can. With the shifting insurance-healthcare model this will only get worse.

The two ways this has become more evident for Defy patients is 1) Increasingly more insurance claims submitted by patients are getting denied for reimbursement of medications once covered. In addition, we now have to charge a small fee just to cover the also increasing amount of paperwork in the form of pre-auths and NDC requests we receive when trying to assist with a claim. 2) We are hearing from many more new patients that it is cheaper to cash-pay for their TRT than to use insurance. It used to be the other way around for those who are lucky enough to have a PCP or insurance covered doctor provide good TRT.

There is another use for anabolic pre-authorization which is worthy of mentioning. This is separate from the information requested by insurance carriers for billing purposes.

Some compounding pharmacies require additional 'pre-qualifying' information prior to dispensing an anabolic hormone other than testosterone. This would include nandrolone and oxandrolone which are now commonly obtained through compounding pharmacies over using manufactured brands. This is due to the increase in regulation over the drug suppliers who supply the raw materials and drugs to compound with. The increase in regulation occurred on the heels of multiple clinics and pharmacies getting investigated and/or shut down due to unethical and illegal prescribing and dispensing of anabolic steroids. For almost a decade many of these clinics operated with little oversight, much like the pain pill mills, until the professional sports scandals brought it to the light. Since there can often be little for the feds to grab onto when trying to prosecute the 'clinics' or pharmacies involved, one way to stop the madness was to put pressure and tighten the regulations on the drug manufacturers supplying the pharmacies in the US. After enough pressure, monetary fines, and/or threat of suspension the drug suppliers began to more strictly investigate and regulate the pharmacies they supply these drugs with. Some compounders now require pre-prescribing information prior to accepting the prescription. This information includes diagnosis in which it will be reviewed by the pharmacist as to if its an approved treatment.

My switch to Defy was motivated by trying to get reimbursed for meds, primarily, I found in Defy what I could afford out-of-pocket. In the case of compounded meds, the bar was set so high for claims, a demand for so much information and everything had to be PERFECT...I couldn't stand it anymore and wrote off what I was paying for meds elsewhere. Obviously Defy has a standard of care second to none with Dr Saya and Jill, but the cost of meds, consults, all made it affordable. For me.

I have excellent insurance but trying to file my own claims for out-of-network and get reimbursed was a Gosh darn nightmare which was particularly atrocious dealing with CVS/Caremark.

In that way, being with Low T Center for a short period of time was fantastic...$15 copay at the door and they filed oinsurance and got their payments which in that one narrow way, they have a superior business model yet fail miserably with their standard of care, weekly in office injections are just one.