Prescription and Pre-authorization Policy
Medications are prescribed in the course of treatment plan review during office visits and a particular medication choice is made at the time. Increasing, there are problems with insurance company delays and denials. Ultimately, the issue of coverage for prescribed medications is between the patient and their insurance policy. As much as we can, we will help in this process and we have dedicated staff to interact with the carriers, but obviously, our resources are limited. At the point where we have exhausted a reasonable effort, we will look to the patient to contact and negotiate with their insurance carrier. There can be other problems with interactions at the pharmacy level. Please review the following:
Sarah Combs is tasked with medication review and preauthorization issues and can be reached through the office phone number, using the prompts. If she is not available, please leave a message. She is diligent about attending to messages and repeated phone calls simply slow down the process. Please leave her time to attend to pharmacy issues.
If a prescription needs “pre-authorization” the process begins at the pharmacy when the prescription is presented. If there is a problem, the pharmacy will fax information to our office to begin the process.
The pre-authorization process may take several days, during which the patient will not have the prescribed medication. Please keep this in mind when making a medicine change.
DO NOT accept “short fills” in which only a partial filling of the medication prescribed is offered. Prescriptions for controlled substances cannot be “called in” and in fact, a hard copy of a replacement prescription must be presented, either by hand or electronically submitted. This may require an office visit to make the arrangements.
Do not wait until the “last minute” to fill prescriptions as we may not have time to work on any problems. This would also apply to the time of day when prescriptions are presented. Friday afternoons, holidays and weekends, the office is not open to deal with issues.
It helps us if you have your insurance company’s formulary available at office visits. Some carriers have very restricted allowed medications which often makes finding a suitable medication extremely difficult. If an insurance company only pays for a few medications, and these medications have not helped or have not been tolerated, then there is clearly a problem. In cases of very restricted formularies, it may be in the best interest of the patient to switch insurance companies.
Increasingly, we are dealing with dictates from the insurance companies that concern such factors as the number of pills allowed in a month, actual dose limits, and types of medicines even permitted. While these constraints may work for the majority, our patients tend to be more complicated and are not well served by these restrictions. Again, a change of insurance companies may be the needed remedy.
Make certain that you have a good relationship with your pharmacy. The pharmacist is an important part of the treatment team and should understand you and your medical problems. Given the enormous regulatory issues and concerns with controlled substances, pharmacists have concerns about issuance of medications, particularly opioids. It is entirely appropriate for patients to share their treatment plans with their pharmacists so that medication rationales are shared.
We have had a disproportionate number of problems with certain chain pharmacies, to the point of suggesting that our patients not use those stores. It may well be that patients will have a good relationship with a particular pharmacist; unfortunately, that person will not always be on duty. A rotating or substitute pharmacist who does not know the patient or the treatment plan can create difficulties.
In general, what has often worked best for our patients is to use an independent pharmacy. We have excellent working relationships with a number of these stores and find that they are willing to provide the care and attention that our patients need. Any loss of inconvenience is more than made up for by the personal care. We can provide suggestions.
A file of resources available for patients to help them obtain and better afford their medications is available. This can be found at the “Resources Tab” or in the binder kept at the office.