Here is a quick lesson/refresher for patients and pharmacists and prescribers who may not know how the system works.
1. Patient is unwell and goes to their prescriber.
2. Prescriber makes a diagnosis and prescribes a medication.
3. Patient goes to pharmacy to have medication filled.
4. Pharmacy fills medication and charges patient the price.
a. price could be cash with no insurance being billed.
b. price could be a copay on their insurance which may or may not include a deductible.
c. price could be on a discount card patient brought to pharmacy.
5. Patient pays and leaves with medication.
This should look similar to every other transaction any person would have at any retail outlet.
1. You decide to purchase a product.
2. You research the product you wish to purchase.
3. You go to the retailer to purchase the product.
4. Retailer finds your product (or you take it to the register) and they charge you for it.
a. price could be cash with no discounts.
b. price could be with an online offer, price match, or in-store sale.
c. price could be with a coupon.
5. You pay for your purchase and go home.
Why is the pharmacy to blame?
They aren't. The ultimate responsibility rests with the patient. If they want/need the medication I, as the dispenser of the medication, have an obligation to tell them how to receive it and provide it to them. That is all. We bill insurances as a courtesy. If your pharmacy has told you your prescription needs a prior authorization, you need to figure out how to get one.
Here is how it works:
1. When filling your prescription, we submit the claim to the insurance we have on file. (note-this may or may not be your most current one. I said it's the one we have on file.)
a. the claim goes through and we get a paid claim with a copay to charge you.
b. the claim rejects for some reason (max days supply, dosing, refill too soon,) and we fix it and reprocess.
c. The claim rejects for "prior authorization required". At this time, we fax your prescriber, then we call you so you don't rush down here. (Sometimes I have called patients while they are still in the office.) We then set up the claim to reprocess in 2 days. and repeat all parts of Step 1 a-c.
2. You accept the terms of our billing process and pay, or not.
3. At any time, YOU can call your insurance to request a prior auth.
Here is my dialogue to patients on prescriptions requiring PA:
"Mr. Pink. We received a new prescription from your doctor this morning and your insurance does not cover it. They require a prior authorization as it is not a preferred item. We faxed the office so hopefully they can start the process. We will reprocess this claim every other day for a week but we suggest you follow up with your provider as no one ever calls us to let us know if the p/a was approved or not. It is possible your provider may wish to change medications or, in some cases, ignore the request altogether. You also have the option to pay cash for your medication which is $$$$$. If you have any questions, please call the office first, your insurance second, and me last. Good Day."
A. "a pharmacist has a duty to tell both the patient and their physician when filling a prescription requires prior authorization."
Yep. We do that.
B. "Pharmacists simply must take reasonable steps to notify patients and prescribing physicians that, if the physician wants a patient to receive insurance coverage for the prescribed medication, the physician must complete a form"
Yep. As I said, we do that. Faxed them. Called them. Told the patient to call them.
C. "it is actually the job of the doctor and insurer to determine coverage."
Yep. Insurance doesn't want to pay. We tell the patient and the doctor.
D. "But once she turned 19, MassHealth's policy was to require prior authorization. Essentially, her doctor had to send a form to MassHealth requesting coverage for the medication."
Wait. So everyone knew this already? First, why does the insurance require prior auth at 19 yo? Did something change? Does it suddenly work differently in an 18 yo patient than a 19 yo patient? But again, if everyone knew this when she was 18, why was this not taken care of by the insurance and her provider beforehand? Why did the patient not make sure she had enough medication to last through the first few weeks/days of the transition?
E. "Rivera's stepfather said he called Schoeck's office seven times about obtaining prior authorization, but he was relying on Walgreens to send Schoeck the form.
Why? Why is it the pharmacy's responsibility to send the form. Look, I can fax 'em, call 'em, drive over there and throw the requests at 'em in the form of little paper airplanes or table footballs but I simply can NOT make them submit the prior auth.
F. " Her family was told it would cost $400 to pay out of pocket, which they could not afford."
Why? Unfortunately the article does not explain which Topamax this is although I suspect it is not the tablets. (If it was an extended release product, why did no one suggest a change to tablets? I can buy #120 Topiramate 100mg tablets for ~$25.00. You mean no one else thought to look at this as a stop-gap option?)
G. "The ruling noted that the pharmacist knows the proper forms and procedures needed for prior authorization, which a patient generally does not."
Nope. I have no clue what the forms are. I do not possess, nor do I know how to obtain them. The reject from the insurance company simply provides me with a phone number for the prescriber to call to get the forms. I know there is a company, Cover My Meds, that takes p/a requests from pharmacies and forwards the correct forms to the providers electronically but that's all I know about it.
So I ask again, why is the insurance not to blame?
