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From Harvard Pilgrim Health Care’s “Why Does Your Drug Require Prior Authorization?” page.

Why does Zyvox (linezolid) require prior authorization?
Zyvox is a very strong and costly antibiotic. It has been shown to be just as effective as other antibiotics currently available to treat infection, however because it is one of the few antibiotics shown to be effective against resistant gram positive infections, infectious disease experts caution that this drug should be used conservatively. The Harvard Pilgrim Prior Authorization Program helps to ensure that this drug is used only when medically necessary.

It’s tangential to why I’m quoting Harvard Pilgrim Health Care’s FAQs, but I have to say the statement that Zyvox “has been shown to be just as effective as other antibiotics currently available to treat infection” is so flagrantly misleading it’s insulting to anyone with more than two neurons to rub together.

The relevance though is that my brother was denied his medication (zyvox) tonight when he went to pick it up from the pharmacy on his way home from the hospital. Two weeks inpatient and he’s not sick enough for the HMO.

“Prior authorization” means he will spend hours on the phone tomorrow trying to get this cleared up. He’ll have to do it himself because if someone tries to advocate for a patient, even a very sick patient, the bureaucrats bust out the HIPAA gags before you can even say “health care proxy”.

So if my brother’s got enough luck, tolerance, and energy to fend for himself with the HMO tomorrow, he might get the drug approved in time for his next dose.

I totally get not wanting people to hand out Zyvox like it’s candy, but a vancomycin resistant MRSA pneumonia really looks like one of those situations for which Zyvox is the best thing going (1, 2) – better than the other antibiotics Harvard Pilgrim’s website nebulously refers to.

Also, I’ve got to wonder…does it really need to be this hard for the doctor, the pharmacy, and the various departments (or rather, databases) at the HMO to get in the same chapter if not on the same page? It’s not like we have to wait for the pony express to deliver the document with the diagnosis on it from the hospital way out East to the HMO head office….er, way out East. We have electronic databases, intranet, and internet. Even the slower connections and programs on poorly maintained 3 years out of date systems (what I hypothesize are used in many if not most medical contexts) are usually faster still than a bike courier at 3 on a Sunday morning in Boston. Point is, I’ll bet if an insurance company had the proper motivation (i.e. business related) to facilitate communication between it’s departments (e.g., that which handles inpatient care claims and that which handles prescription coverage), we’d see that info moving so fast you’d think it was magic.

Update 10/16/07, 7:12 PM. Hospital has faxed “the form” and the HMO is doing whatever it does which we would consider mulling it over. And my brother is going without antibiotics for two doses and counting.

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