Pharmacists and Insurance Companies

 

 

Over the past few years, pharmacists have become important allies to my patients in medication-assisted treatment. I’m thankful for that, since it makes my patients’ lives easily, and mine. But recently, there have been some minor bumps in the road, made more pronounced because of their decreasing frequency.

Sometimes, I get cranky.

I got a message from my office staff person that a pharmacy had called because I didn’t write any dosing instructions on a prescription I had just written. “Wow,” I thought, “I must be losing my mind.”

We copy all prescriptions, so I looked at our copy. It looked complete, except under instructions, I’d written 1 ½ SL. I had neglected to write “Qd” which means once daily.

My bad. I should have written it. How else would a pharmacist be able to guess what the instructions are…except I wrote for #45, a month’s worth. And the patient has filled prescriptions for 1 ½ SL qd for about three years now, all filled every month at this pharmacy. Nope, no way for the pharmacist to decipher this riddle.

Well, I can’t really blame them; it was my mistake.

Last night I got a call from a patient who was enraged because the pharmacy was refusing to fill his prescriptions. I know this patient very well, and though he’s been doing well in recovery for about ten years, he can get angry if he misunderstands things. I told him I would call the pharmacy to try to figure out the problem.

I see this patient every two months, and my last prescription was written with a refill. He filled the first prescription a few days after I saw him. When I finally got to speak to the pharmacy manager, he said they had ordered the medication for the patient, and he would be able to pick it up the next day.

OK, I said, but that’s actually five days late, due to the pharmacy not having the medication in stock. The pharmacist didn’t seem disturbed that his patient would have been out of a life-sustaining medication for five days, so I asked why it was that the medication couldn’t be ordered so that it would be in stock when the patient was due to pick it up.

The answer shocked me with its honesty. He said the pharmacy didn’t want to risk getting ‘stuck” with the medication if the patient decided to go somewhere else to fill it, and that “these patients” flew from one pharmacy to another all the time, in order to save one dollar.

What I should have said…was something along the lines of, “You’re an asshole who shouldn’t be in the helping professions. Do you do the same thing to diabetics on insulin?”

What I did say was…nothing. I was so stunned at the lack of compassion that I didn’t say anything. I’m disappointed in myself for this, since I’m usually a little spicier. His honesty took me completely by surprise, as did his naked disregard for the well-being on my patient.

Then there was the phone call last week from a pharmacist who wanted to make sure the patient hadn’t changed the prescription. Again, this was a patient in recovery for years, whom I see every two months. I wrote her prescription for Suboxone 8mg films, one per day, #30, and I printed out “ONE” under the line for refills, as I’ve done for the past four years.

The pharmacist wanted to know if I had written a zero and the patient falsified and wrote the “NE” after it.

I suppose that’s possible, but I except I print very clearly, and the “O” that the pharmacist thought could be a zero was way on the left side of the blank for number of refills.

This problem that will go away after electronic prescribing, mandated by the state of North Carolina, is in place. I’ve stuck with old-school paper records and hand-written prescriptions for as long as I can, but that will be a thing of the past by January 1, 2020.

I’ve saved the most insane for last.

A local pharmacy called, stating that my one-month written prescription for a patient for suboxone films was partly voided because of the insurance company’s decision.

Huh? How does this happen, I wondered.

I’m still not sure, but here’s what I was told that the pharmacist was told by the insurance company representative.

The visit prior to this one, I had written only a two-week prescription. I don’t recall what was going on, but I needed to keep a closer eye on the patient, and changed from my usually monthly prescription.

Apparently, this was the root of the problem. I wrote for #45, a 2-week prescription. Then at this last next visit, two weeks later, I decided the patient could go back to monthly visits and wrote for #90. This caused a red flag on the patient, because he had now was trying to fill #135 films within a thirty-day period. Yeah…except for the patient already took the forty-five films during a two week period that was already past.

I can’t make this stuff up.

So his insurance company said nope, you can only get #45, which will make only #90 in a thirty-day period. And the pharmacy “cancels” the rest of my ninety day prescription.

Insurance companies would make the Buddha want to bitch slap someone.

I told the staff member who took the call, “Please get the insurance company’s physician reviewer on the phone. I’ve got to hear this logic. I also need to speak to the pharmacist. I want to know exactly who thought they had the right to cancel a prescription, written by a physician, for no medical reason.”

I was riled, and kind of looking forward to what could be a very interesting conversation. But it was not to be. When my staff called the pharmacy, this situation mysteriously resolved itself. No problem now. Patient can come by to get the other #45 films, and insurance won’t give him a hard time when he comes next month with a month’s prescriptions.

Despite these experiences, most pharmacists know how important buprenorphine products are to the recovering person, and are positive and supportive of my patients on medication-assisted treatment. There are far more of these than the pharmacists who have biases against patients on MAT. It’s just that the troublesome ones stand out by their behavior.

I am a peaceful person. I intensely dislike confrontation and can get along with almost anyone. But there are times, large and small, when I have to get out of my comfort zone and make some noise.

 

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8 responses to this post.

  1. Posted by Steve Straubing on December 9, 2018 at 11:13 pm

    What a timely blog! On Friday, I was informed that a very large pharmacy chain now was refusing to dispense buprenorphine; only Suboxone because of SAMHSA guidelines. Most of my patients have either no insurance, or no coverage for Suboxone, because even though there is so called parity, the powers that be in my state, have a great deal of difficulty understanding that buprenorphine is an important med.
    As a result, I prescribe buprenorphine for most of my patients, well aware that there probably is an increased risk of diversion but that ethically I should provide a lifesaving medication nonetheless.
    I pointed out to the corporate office that SAMHSA and other guidelines are exactly that; guidelines which don’t take the place of clinical judgment and individual pt needs.
    I suspect my complaints won’t go very far so I’ve directed my concerns to our state society of addiction medicine and to ASAM.
    Add this to your list of Buddhistic Bitch Slaps

    Reply

  2. Posted by Jim Woodall on December 10, 2018 at 1:59 pm

    There are, unfortunately, people in the pharmacies, and the insurance companies that have total disregard for people with addiction problems. It is not only there, I have tried to get a PCP, since mine had died suddenly last April. I went to one of the Doctors in the same office that did not prescribe suboxone, which didn’t matter, because I would be getting the suboxone from another Doctor who was capable of prescribing. The nurse had called me, and told me she did not prescribe suboxone. I told her I wouldn’t need her to prescribe that medication. When I went to the visit, she was very rude, and let me know she had nothing to do with suboxone. She starting asking about other medications I was prescribed. I was on lexapro and Wellbutrin for depression. I had a 14 year son die in my arms, while he was awaiting a heart transplant. I was devastated and the images of that day stayed with me, even though it had been many years ago, it is something you never get over. Dr. Birdsall understood this, and he prescribed the medication. She asked if I was seeing a psychiatrist, I said no, at first I did, but after many years I felt I just needed the medication. She said I would have to see a psychiatrist to get that medication. I could see immediately where this was going, she did not want to deal with me because I was on suboxone. Once I had enough, I just got up and walked out. It has been very hard finding a Doctor who is compassionate about your problems, including addiction. It seems some of them just prescribe the suboxone only, and don’t deal with the other problems, and the ones who deal with the other problems don’t prescribe suboxone. Dr. Birdsall was a great Doctor who cared about ALL of your problems, but Doctors like him are hard to come by. Dr. Bursen, from what I’ve read you seem just like him, I just wish you were down here in Cajun country, Boutte Louisiana.

    Reply

  3. Posted by Steve Straubing on December 10, 2018 at 3:54 pm

    Jana, email me directly to discuss

    Reply

  4. Posted by Armymom02 on December 13, 2018 at 4:46 pm

    And the government wants to know why there is an opiate crisis..even when in recovery youre treated like a full blown addict.!!

    Reply

  5. Posted by Joseph Toney on December 18, 2018 at 7:13 pm

    I am a Family Physician who spends a majority of my time treating patients with OUD. I agree that insurance companies and pharmacies at times can be frustrating but the vast majority of the time Pharmacists are a huge ally. They often catch my oversights or mistakes. My local pharmacy spends a massive amount of time on the phone advocating with insurance companies for our patients. They also provide a respectful and open environment welcoming patients struggling with addiction and really area a continuation of what we have tried to achieve here at the clinic.

    Reply

  6. Posted by Lisa Brawley on December 18, 2018 at 10:41 pm

    The thirty day look back is very confusing when you transfer a patient from weekly or bimonthly scripts to monthly scripts. It prevents the patient from being given more than thirty days of medication in any thirty day period of time. The pharmacist has to call the insurance company help desk and ask for an override. “The patient was getting weekly scripts and is now getting monthly scripts, can you give me an override”. I was surprised to find out that not all pharmacists knew how to do this, but just like us doctors learning how to get prior authorizations to go through it takes a lot of trial and error and some dogged persistence because they sure don’t teach you this in school.

    Reply

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