This is the time of year when lists of favorite things are shared widely. With that in mind, this month, I share some of our favorite healthcare-related “scripts” for managing common healthcare situations.
If you need prior authorization or a formulary exception for medications in 2026…
Many medications require a process in which medical documentation must be submitted to the prescription drug company or Medicare Advantage Plan (MAP) to show that the drug is medically necessary, so it can be approved for payment.
Some plans may have the medication on their formulary, and so the process is called a prior authorization. Others may not list the medication, so you must file for a formulary exception. Some plans refer to these situations as filing for a Coverage Determination/Exception. Here’s how best to manage the process soon after January 1st, when your plan becomes effective.
Call the prescribing physician’s office and say:
My new prescription drug plan states that _____ medication requires a prior authorization or formulary exception. Who in your office takes responsibility for such things, and what is the best way to make my request?
I understand the physician must provide medical documentation to substantiate the need for the medication, so I want to be sure the relevant information is included with the request. I’d like to get it started right away, as the plan is required to respond within 72 hours, but if it is denied, and an appeal is required, the plan has seven days to respond. I cannot be without my medication, so I’d like to get started. I set up a member portal so I can monitor the process once you initiate it.
If your physician leaves the practice and you are thinking of finding a new one elsewhere…
I have written previously about our nationwide shortage of primary care providers. There are many reasons for this, but one key takeaway is that if you have been assigned a new physician and are thinking of leaving the practice, know that finding a new provider will not be fast or easy.
So, before simply leaving, I recommend contacting the practice manager and setting up a phone meeting. Begin by saying:
I’m calling to speak to the practice manager or administrative person within your practice who is responsible for patient satisfaction.
Once you find them, say:
I’m calling to discuss my experience with your practice. I’ve been with you for years and had a wonderful relationship with Dr. ___________. But since her retirement, my experiences have led me to consider leaving the practice. Before I do, I thought I would try discussing my experiences with you so that maybe we could solve problems together. I know physicians move on, but I’ve now been randomly assigned to new physicians without any discussion about my needs and what I’m looking for. I know how critical a good relationship with my doctor is to my wellbeing, so how can we work together to overcome this issue?
If you are having a diagnostic test performed…
One of my pet peeves is when a healthcare professional does not introduce themself or manage your expectations during an encounter. As you are called from the waiting room and asked to follow someone with no explanation, say:
Excuse me. My name is ___________, and your name is __________? I’m here for an abdominal MRI. Are you the person who will be assisting me with that? I’ve never had one before, so I’m a little anxious. With all your experience helping patients complete this test, please share your knowledge with me. I’d like to know exactly what to expect.
If you are accompanying someone to a healthcare appointment…
I don’t think anyone should attend physician appointments alone, especially when managing complicated medical issues. Bring a Care Partner with you and ask them to say the following:
Hi, I’m ________ and I’m Jean’s Care Partner. She asked me to attend this appointment with her so I could be a second set of listening ears, take notes for her so she can pay close attention to you, and ask a question she might not think to ask. It’s nice to meet you.
If your loved one is called “honey”…
This is another one of my pet peeves — calling adult men and women honey.
Thank you for extending your warmth and kindness to my mom by calling her honey. She prefers to be called Mrs. Savastano or Anne.
If an older loved one has received a life-threatening diagnosis…
Throughout my career, I’ve worked with individuals in the final stages of their lives. Creating a dialogue about life coming to an end with an individual, a family member, or a provider is never easy. Here are some examples from an experience with a 92-year-old client.
With Rose:
When Dr. Burns did a test on your abdomen because you were having trouble going to the bathroom, he saw a large mass in your belly, and he suggested you see a surgeon. How do you feel about that? How would you feel about having surgery?
With her family:
Dr. Burns, Rose’s urologist, conducted an ultrasound on Rose’s abdomen that revealed a large mass. He suggested your mom see a surgical oncologist. How do you feel about that?
With her doctor(s):
It sounds as though surgery may be an option you are considering for Rose. What are the risks and what would you expect for her recovery? What are the alternatives?
What do you anticipate would happen if Rose chose not to have surgery?
What could be done to mitigate any suffering she might experience?
Rose had the surgery, has had a major complication, and you are suggesting another intervention. What information will that give us? How will it improve Rose’s life? What if we did nothing?
Summary
We all have a responsibility to become educated about the healthcare and health insurance systems, as they are inextricably related. One way to do that is to identify experiences you find uncomfortable and create a strategy for addressing them.
In general, the professionals you encounter want to be helpful and are often equally frustrated by “the system.” The more able you are to calmly and clearly communicate your wants and concerns, the more likely you will experience the outcomes you desire for yourself and your loved ones.