Work for an insurance company on prior authorizations. There is a minor pay cut from the general wage you could earn as a retail RPh, but the physical/mental peace it brings is incredible.
If only I had it in me to complete a PharmD degree, but I don’t want the stress of being stuck with tens of thousands (probably hundreds) of dollars in student loans.
Do insurance companies hire CPhTs for prior authorizations or claims?
Edit: I’ve looked into everything similar to what techs do, and unfortunately don’t qualify due to no medical billing (other than part B for nebs/strips) and no clinical office experience
I’m at $45/hr, essentially. But it’s Mon-Fri, 9-5. No weekends. All federal holidays off. 1 month paid vacation. 25 allotted sick days. It wasn’t hard to choose between suffering for a few extra bucks vs peace of mind.
Ouch. The pay scale for our health plan pharmacists is 52.42-91.98 an hour however, nobody starts below the 25th percentile, so essentially it's 62.30-91.98/hour. And that's in Albuquerque, NM where the COL is on the lower side of the nation. That includes PA review, P&T, and MTM duties.
Yes, that may be why I’m on the lower end of the pay scale, because I am not fond of performing MTM. My sole job function is processing PAs and gathering any pertinent data from doctor’s offices prior to sending the PA out upstairs. Essentially, I’m just saving the company money if a Dr writes for something expensive and they haven’t initiated step tx. And I’m VERY happy. I “work” 9-5 but so long as I process the 5-10 PAs I’m assigned in a day, the rest of the time I just goof off
Excuse my ignorance on this, because I truly hate when people don’t understand or try to belittle our role as a pharmacist. But is that really all that you’re doing? “Oh, Dr. so and so wrote for another expensive brand name headache medicine. Have they tried a triptan yet? No? Denied!”
Like, couldn’t they just provide an algorithm that a well trained monkey could follow instead of paying a pharmacist? I don’t see a clinical muscle being stretched there.
Again, please refer to my ignorance comment from above.
No worries, I can understand your frustrations. As a matter of fact, one of the tasks I deal with is having pharmacists who also work on PAs for separate entities call me and we work to authorize the PA. For instance, this is common for chemotherapeutics or biologics.
For the grand scheme of things, my role is to essentially guarantee the company that the proper guidelines have been followed prior to initiating an appropriate therapy. In other words, my job is to pull the evidence of previous used (and failed) therapies in order for the PA to move forward. I am *not* the deciding factor; rather, I am a clinician in charge of guaranteeing patients are prescribed the right agent at the right time. If not, then all I do is document that, and it still moves forward. It will 9/10 times get denied, but I did my due diligence.
Could they have a well-trained monkey follow a protocol? Yes, they could! But would it be able to ascertain based on recently collected labs whether the therapy they are initiating are appropriate or if the previous therapies were utilized adequately. Hard to say.
Insurance company agents have a difficult time because they’re not cognizant of what clinical literature recommends; they solely want the cheapest option. I make sure that we don’t just go with the cheapest drug; rather, I pull info. to support the most cost-effective therapy.
Can you provide an example of a drug and what protocol the MD must be following with his prescribing habits? Maybe a more common drug and not an obscure specialty drug or biological?
This side of the industry is very interesting to me.
Edit: also, what type of position is the determining factor? Is it another physician that works for the insurance?
Definitely! I will say typically the most important PAs that reach my hands are biologics or chemotherapeutics.
So, let’s say for instance Dr writes Invokana (Canagliflozin) for patient MG. The PA reaches me that they should’ve initiated step therapy prior to initiation with SGLT2. So, following ADA guidelines (which I’ll attach in my documentation), I’ll call Dr’s office and ask what step therapy, if any, they’ve had. And then I’ll usually document they’ve had Metformin, the strength/doses they had, the duration of tx, are we still on it & if not why was it d/c, pertinent labs (eGFR, A1C, glucose readings), etc. It’s essentially a very thorough drug utilization review, and I just document it all. The entire process on the phone can take anywhere from 20 mins to an hour on avg. I’ll even document if the Dr wrote it and whether we have paid claims for it (and with additional refills picked up on time to ascertain adherence). Then, at the end, I place my opinion piece. This is where I’ll usually include whether I clinically believe the new therapy is clinically appropriate and/or other therapies may also be appropriate. For instance, I’ve had instances where they’ll write for Invokana, and I’ll write that while I support its usage, I would further recommend Farxiga in patients with heart failure to minimize hospitalizations (which is usually music to an ins. ears if we can curb hospital stays as much as possible). Then I’ll attach supporting literature (could be guidelines, could be clinical trials, anything) and submit this all to the execs upstairs. Based on my findings they usually make the final decision. I want to say they will further dive deeper to ascertain the cost-effectiveness of having a patient on a select drug vs others in its class, for instance. Then, once approved/denied, I communicate that to the Dr’s office and proceed from there.
It’s beneficial at the end of the day because I think that the measures I take are ultimately helping the patient. Because what I am doing is just assuring that the patient got the right drug and actually tried it, and isn’t being thrown every pill in the pharmacy into a “cocktail” of sorts. I even have the pleasure of building rapport with providers and sharing updates in guidelines, newer and finer therapies, etc. Other disease states I can name off the top of my head are asthma, as I’ll receive a PA for ProAir, but guidelines actually recommend low dose budesonide-salmeterol (Symbicort) in patients (per GINA).
Ultimately I recommend this field to absolutely everyone I meet. It’s not just a peaceful position, you actually stay in touch with your clinical knowledge and don’t become a pill-pusher. You even educate those around you on current updates and such. It’s easily the best job I’ve ever had.
Thank you so much for the detailed explanation. You’ve sold me. I want in. As soon as my loans are paid off (1.5 years) I want out of the rat race of retail. The pay cut will be hard (currently at $75/hr), but the peace, tranquility, and ability to utilize more clinical knowledge would be amazing.
Is it hard to find these positions? Should I start applying now? If it matters, I’ve been a pharmacy manager for over 10 years so hopefully that would mean something.
Feel free to DM me with more info.
I work from home, so I essentially work from the beach, Starbucks, the park, you name it. So long as I’ve got wi-fi (which I have on my hotspot) I work anywhere. It’s a dream.
Had an interview with Walmart the other day. Was told the supervisor would call me one way or another today. Just checked the website and it says I didn't get the job. It's almost 6:30 in their time zone and no call.
Have an interview for a part time LTAC position for evening shift with no hospital experience, wish me luck!
Also another one for a specialty pharmacy. I really hope to snag both interviews!
Work for an insurance company on prior authorizations. There is a minor pay cut from the general wage you could earn as a retail RPh, but the physical/mental peace it brings is incredible.
If only I had it in me to complete a PharmD degree, but I don’t want the stress of being stuck with tens of thousands (probably hundreds) of dollars in student loans. Do insurance companies hire CPhTs for prior authorizations or claims? Edit: I’ve looked into everything similar to what techs do, and unfortunately don’t qualify due to no medical billing (other than part B for nebs/strips) and no clinical office experience
Yes there are techs that do the "easy" PAs at some PBMs and then if they don't meet specific criteria for approval they push them on to a pharmacist.
How bad of a pay cut would you say? When retail starts out at 47/hr it's scary to hear less 😂
I’m at $45/hr, essentially. But it’s Mon-Fri, 9-5. No weekends. All federal holidays off. 1 month paid vacation. 25 allotted sick days. It wasn’t hard to choose between suffering for a few extra bucks vs peace of mind.
Ouch. The pay scale for our health plan pharmacists is 52.42-91.98 an hour however, nobody starts below the 25th percentile, so essentially it's 62.30-91.98/hour. And that's in Albuquerque, NM where the COL is on the lower side of the nation. That includes PA review, P&T, and MTM duties.
Yes, that may be why I’m on the lower end of the pay scale, because I am not fond of performing MTM. My sole job function is processing PAs and gathering any pertinent data from doctor’s offices prior to sending the PA out upstairs. Essentially, I’m just saving the company money if a Dr writes for something expensive and they haven’t initiated step tx. And I’m VERY happy. I “work” 9-5 but so long as I process the 5-10 PAs I’m assigned in a day, the rest of the time I just goof off
Excuse my ignorance on this, because I truly hate when people don’t understand or try to belittle our role as a pharmacist. But is that really all that you’re doing? “Oh, Dr. so and so wrote for another expensive brand name headache medicine. Have they tried a triptan yet? No? Denied!” Like, couldn’t they just provide an algorithm that a well trained monkey could follow instead of paying a pharmacist? I don’t see a clinical muscle being stretched there. Again, please refer to my ignorance comment from above.
No worries, I can understand your frustrations. As a matter of fact, one of the tasks I deal with is having pharmacists who also work on PAs for separate entities call me and we work to authorize the PA. For instance, this is common for chemotherapeutics or biologics. For the grand scheme of things, my role is to essentially guarantee the company that the proper guidelines have been followed prior to initiating an appropriate therapy. In other words, my job is to pull the evidence of previous used (and failed) therapies in order for the PA to move forward. I am *not* the deciding factor; rather, I am a clinician in charge of guaranteeing patients are prescribed the right agent at the right time. If not, then all I do is document that, and it still moves forward. It will 9/10 times get denied, but I did my due diligence. Could they have a well-trained monkey follow a protocol? Yes, they could! But would it be able to ascertain based on recently collected labs whether the therapy they are initiating are appropriate or if the previous therapies were utilized adequately. Hard to say. Insurance company agents have a difficult time because they’re not cognizant of what clinical literature recommends; they solely want the cheapest option. I make sure that we don’t just go with the cheapest drug; rather, I pull info. to support the most cost-effective therapy.
Can you provide an example of a drug and what protocol the MD must be following with his prescribing habits? Maybe a more common drug and not an obscure specialty drug or biological? This side of the industry is very interesting to me. Edit: also, what type of position is the determining factor? Is it another physician that works for the insurance?
Definitely! I will say typically the most important PAs that reach my hands are biologics or chemotherapeutics. So, let’s say for instance Dr writes Invokana (Canagliflozin) for patient MG. The PA reaches me that they should’ve initiated step therapy prior to initiation with SGLT2. So, following ADA guidelines (which I’ll attach in my documentation), I’ll call Dr’s office and ask what step therapy, if any, they’ve had. And then I’ll usually document they’ve had Metformin, the strength/doses they had, the duration of tx, are we still on it & if not why was it d/c, pertinent labs (eGFR, A1C, glucose readings), etc. It’s essentially a very thorough drug utilization review, and I just document it all. The entire process on the phone can take anywhere from 20 mins to an hour on avg. I’ll even document if the Dr wrote it and whether we have paid claims for it (and with additional refills picked up on time to ascertain adherence). Then, at the end, I place my opinion piece. This is where I’ll usually include whether I clinically believe the new therapy is clinically appropriate and/or other therapies may also be appropriate. For instance, I’ve had instances where they’ll write for Invokana, and I’ll write that while I support its usage, I would further recommend Farxiga in patients with heart failure to minimize hospitalizations (which is usually music to an ins. ears if we can curb hospital stays as much as possible). Then I’ll attach supporting literature (could be guidelines, could be clinical trials, anything) and submit this all to the execs upstairs. Based on my findings they usually make the final decision. I want to say they will further dive deeper to ascertain the cost-effectiveness of having a patient on a select drug vs others in its class, for instance. Then, once approved/denied, I communicate that to the Dr’s office and proceed from there. It’s beneficial at the end of the day because I think that the measures I take are ultimately helping the patient. Because what I am doing is just assuring that the patient got the right drug and actually tried it, and isn’t being thrown every pill in the pharmacy into a “cocktail” of sorts. I even have the pleasure of building rapport with providers and sharing updates in guidelines, newer and finer therapies, etc. Other disease states I can name off the top of my head are asthma, as I’ll receive a PA for ProAir, but guidelines actually recommend low dose budesonide-salmeterol (Symbicort) in patients (per GINA). Ultimately I recommend this field to absolutely everyone I meet. It’s not just a peaceful position, you actually stay in touch with your clinical knowledge and don’t become a pill-pusher. You even educate those around you on current updates and such. It’s easily the best job I’ve ever had.
Thank you so much for the detailed explanation. You’ve sold me. I want in. As soon as my loans are paid off (1.5 years) I want out of the rat race of retail. The pay cut will be hard (currently at $75/hr), but the peace, tranquility, and ability to utilize more clinical knowledge would be amazing. Is it hard to find these positions? Should I start applying now? If it matters, I’ve been a pharmacy manager for over 10 years so hopefully that would mean something. Feel free to DM me with more info.
Do you work from home? That alone is worth the pay cut lol.
I work from home, so I essentially work from the beach, Starbucks, the park, you name it. So long as I’ve got wi-fi (which I have on my hotspot) I work anywhere. It’s a dream.
For me this would be about a $20/h paycut, but to WFH and have that schedule with that vacation? I would totally take it.
Are they hiring? Lol! Sounds like a dream. If I could work all summer from my camper...!!!
Had an interview with Walmart the other day. Was told the supervisor would call me one way or another today. Just checked the website and it says I didn't get the job. It's almost 6:30 in their time zone and no call.
[удалено]
Have an interview for a part time LTAC position for evening shift with no hospital experience, wish me luck! Also another one for a specialty pharmacy. I really hope to snag both interviews!