How a specialty pharmacy denies a physician his medication

Holy crap.

My medication did not arrive today.

How can this possible be happening?  Do they not know this medication is not optional?

Let me recap.  I called over a week ago for a refill.  I am only allowed (by my insurance) to use the (non-local) specialty pharmacy that they own for this medication.  They told me my medication would arrive yesterday, which was the day after I’d use my last pill.  Even though that was cutting it close, that was their plan.  The meds did not arrive and I received instead a cryptic message I was lucky to catch and return.

The specialty pharmacy – the only one I am permitted to use – had my medication on backorder.  And didn’t tell me until the day it was to arrive.  When it was absolutely impossible to do anything about it.  The person at the pharmacy swore it would be delivered today.

She lied.

I just got off the phone with them.  After being put on hold for 10 minutes, they came back and said they don’t know what happened.  It will now be here Thursday.

I explained to them that this medication is not for fun.  I must take it.  They apologized for my inconvenience.  I told them I wanted to go to my local pharmacy and get it.  They told me to call my insurance prescription plan.

I did.  Now I know the nice woman at the end of that line isn’t to blame.  But I hate them all now.  She again apologized for the inconvenience.

Anyway, she suggested I get my doctor to call in an “emergency script” for a few days’ meds and then go to the local pharmacy and ask them to call the insurance company (while I wait) and fight with them to get it covered even though it’s not the specialty pharmacy I’m supposed to use.  I explained that (1) it’s 9:30 at night and my doctor is not available, (2) I have to work tomorrow and can’t stand at the pharmacy in the middle of the day while they “fight” with the insurance company, and (3) it’s all moot anyway because I’m now two days without meds and there is nothing they can do to fix that.

Nor do I believe what any of them say anymore.

I can’t believe how frustrated and helpless I feel.  I am playing by the rules.  I’ve missed no payments, no visits, no deadlines.  They are keeping me from my necessary treatment by forcing me to use a pharmacy that runs out of meds, lies about it, does not inform me, and then does not have a solution.

This is not an “inconvenience.”  I’m being hurt – literally.  They are denying me the medication I need to stay healthy.  Them.  Denying me.  It’s not an inconvenience.  It’s an assault.

Aaron E. Carroll is an associate professor of Pediatrics at Indiana University School of Medicine who blogs at The Incidental Economist.

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  • http://www.sufficientscruples.com Kevin T. Keith

    This is infuriating and heartbreaking. You have my fullest sympathy.

    But I can’t help noting that this sort of thing is absolutely everyday commonplace for most people in the US – the ones that have insurance at all, that is. It’s hard to imagine that a physician who likely has what passes for relatively decent insurance, by US standards, has fewer options or less influence than most of his patients. Your patients are being assaulted – sometimes to the point of threatening their lives – every single day. And you are absolutely right, “assault” is not too strong a word for it – corporate assault by the for-profit medical system and the vultures who benefit from it. But again, this is the status quo for almost every one else.

  • Dr. J

    I would argue that you have been injured by the pharmacy and the insurer and depending on your contract you probably have a contractual breach or a tort claim to make against them.
    The reality is that complaints by you or any other patient are totally meaningless because there is not a true free market for medical care or insurance so they know they cannot loose your business. What talks is dollars, and if you are upset enough you should seek financial redress through the courts to make them actually pay.
    Dr. J

  • Moshe

    While I don’t know which medication it is, your health might just be better if you went out and bought a couple days supply out of pocket.

    If the meds are expensive, you can then sue the specialty pharmacy in small claims court.

  • mjadala

    Wait, do I work with you? I heard almost exactly the same story from one of my co-workers a couple of weeks ago. It should not be so hard to get important (potentially life saving) drugs. I don’t get it and there is got to be a better way

  • Tim Martin, MD

    I have seen the exact scenario played out in the lives of my patients countless times. This is also the same process my staff and I go through to get many standard and routine types of tests done – MRI for exam documented lumbar radiculopathy, stress test for man with diabetes, hypertension and unstable angina, etc.

    Furthermore, many prescription management companies are currently soliciting the physician to change his/her patients medication to a non-equivalent med – Actos plus met to glipizide alone, or Crestor to lovastatin, avodart to cardura.

    Cutting healthcare costs is resulting in worse healthcare, not intelligent examination of areas where some of the actual overspending is going on – inappropriate ER visits, expensive walk- in clinic care, well woman visits costing over $3000 once all the tests and labs are accounted for.

    Let’s quit skimping on critical diseases like diabetes and coronary artery disease and start looking at curtailment in convenience and too expensive routine care. And let’s quit requiring our trained and licnsed to justify their decisions in the middle of their busy clinic schedule.

    When I have to talk to the doc on the other end of the line at the insurance prior auth dept, I have started taking their name and ID information to pass on to my patient, since they are using their MD license to consult with me to tell me my patient does not need the test I am ordering. I just want my patient to have someone to follow-up with.

    • AustrianSchool

      “Cutting healthcare costs is resulting in worse healthcare”…and increases costs. When this man calls for a local refill, guess what, his doctor will likely and appropriately request he come in and be seen, costing him and his insurance company even more money.

  • SarahW

    Buy the medicine out of pocket and sue them if a demand for reimbursement fails. You’ve taken every reasonable step to obtain your medication under their terms – they failed to live up to their end of the bargain and left you without recourse.

  • http://warmsocks.wordpress.com/ WarmSocks

    This exact scenario was my fear when we switched insurance. I was given the direct phone number of the person in charge of our group’s plan, and was instructed to call if my medication didn’t arrive when it was supposed; he would pull the strings necessary to get my Rx at the local pharmacy.

    The telephone number on your insurance card isn’t the one you need. What you want is the number of the person who can fix things for you. Your human resources department can get you that number (given that you’re at a university, that person might be someone in your HR dept who dictates to the insurance company what to do). Good luck.

  • http://womenshealthnews.wordpress.com RachelW

    The advice from a couple of commenters to just “buy the med out of pocket” and then wait for payment is well and good only if a patient actually has the resources to do that. The original poster might, but there are surely plenty of people who not only cannot afford to pay out of pocket, but cannot afford the time off work needed to get to and wait at the other pharmacy trying to get it sorted out.

  • pcp

    “she suggested I get my doctor to call in an “emergency script” for a few days’ meds and then go to the local pharmacy and ask them to call the insurance company (while I wait) and fight with them to get it covered even though it’s not the specialty pharmacy I’m supposed to use.”

    As always, the “solution” involves everyone but the entity that caused the problem doing extra work to fix the mistake.

    Do what I tell my patients on an almost daily basis: file letters of complaint with your HR rep, the state pharmacy board, and the state insurance board. If these parasites want to pretend to be pharmacies, make them play by the rules.

  • aek

    You can also contact YOUR physician and request that he or she advocate for you to the insurer. as well as evaluate whether there is another timely alternative treatment for you.

    Meanwhile, contact your state’s attorney general’s office.

    I think it’s a shock when physicians and nurses are patients and are hit (intentional pun) with the need to provide self advocacy.

    What’s happening to you is an outrage and should not be able to be allowed to happen to anyone under any circumstances.

    • pcp

      “You can also contact YOUR physician and request that he or she advocate for you to the insurer”

      You want me to cancel four appointments with sick patients and spend an hour on the phone talking to high school drop-outs sitting in front of a computer?

      Not a good use of my time.

  • Tim Martin, MD

    While there are many alternatives to deal with this problem, I’m hearing a larger problem pointed out. Something like: our system has evolved to the point that we are prisoners of what is convenient and cheapest for the company that provides our insurance. As a physician who advocates for my patients, I can tell you that I am treated no better than my patients are when I finally make contact with someone at the insurance companies office. I’m not sure what would influence insurance companies to do things differently except for government regulation or lawsuits, both of which are terrible ways to solve a problem.

  • docguy

    i doubt you can sue your insurance company i’m sure you signed a arbitration clause somewhere.

  • http://Everythinghealth.net Toni Brayer, MD

    Please don’t call your PCP and ask that he/she fight for you. When you read what you have gone through, and understand that it is not an aberration but every day “business as usual” for insurance companies…why would you inflict more on the busy, overworked, underpaid doctor? We are just as helpless against this machine as you are and are busy advocating for hundreds of patients who are denied claims, insurance coverage and meds.

    Take the time and go to your insurance commissioner, State AG, medical society and any place else that influence can be sought. Buy your meds and take the insurer to small claims court (claiming your loss of income also) just for the hell of it.
    I share your frustration and have empathy for all patients who are jacked around on a daily basis by insurers.

  • soloFP

    The mail order pharmacies are a hassle. Often the 90 days generics cost the paitent $20 in the mail when they would only be $10 at Walmart. The patients often forget to reorder meds and do not sign up for autofill/auto charge the credit card. Daily I get calls needing a 7-10 day local supply called in while they are waiting for the mail order supply. With the push for mail order meds and rxes throught the mail, I waste at least another 4 hours a week dealing with the mail order requests. The copay savings only is 3 months for the price of 2 copays, yet the insurance companies saves tons with mail order meds. More free work is now coming from the doctors.

  • http://drpullen.com health blog

    This is not accidental. It’s absolutely ruthlessly on purpose. Every day you don’t get a pill is one less pill they have to pay for and they live by their quarterly profits.

    • ninguem

      What health blog said.

      It is not an accident, it is not an inconvenience, it is absolutely, ruthlessly on purpose, deliberate, and they could care less if it resulted in your inconvenience, injury, or death.

    • Molly Ciliberti, RN

      Wow, I hadn’t thought about that, but it is a clear possibility since they only understand money.

  • jerry

    Ask the government to take over your health care? Ask lawyers to get involved? or
    Stop paying for trivial insurance and only purchase catastrophic coverage. Your doctor would prefer cash and will give you a discount anyway. The drugs are so important that they are worth the cash.

    • jerry

      That sounds harsh, but if they make cash providing you service instead of profits by denying you care then you may be better off without that kind of a drug plan or insurance.

  • Leo Holm MD

    While this kind of criminal behavior is routine for insurance companies; doctors are increasingly scrutinized with audits, satisfaction surveys, quality improvement metrics, online reviews, etc. How about “pay for performance” for insurance and drug companies? Try this:

    Didn’t get your prescription on time? Refund the years premiums.

  • Sideways Shrink

    I prescribe stimulants that are Schedule II for ADD. What gets to me is that a lot of insurers are putting a lot of financial pressure on patients to pressure prescribers to prescribe 90 day supplies of these medications through these mail order pharmacies. For starters, I can’t believe any state pharmacy board allows 90 day supplies of a Schedule II to be dispensed and mailed across state lines. Or that the DEA Diversion program would not make that illegal. Regardless, I am not taking that risk regarding diversion or suicide.

    • ninguem

      And I’m impressed how many patients report the delivery just dispensed with any signature requirement and just left the Schedule-2 drug on a doorstep.

      • Lisa

        All the time I get notices from my insurance company to order my meds, which includes a stimulant, by mail. Even though I see my psychiatrist every 3 months, she absolutely, positively will not give me 90-day prescriptions so I can do mail order. Every month I make a trip to the pharmacy to fill my prescriptions. It’s a little more expensive, but it’s no big deal.

  • Dr Chris

    This kind of conundrum is not uncommon-I get stuck trying to help patients at elate 2-3 times a week with something like this,
    Most recently, an insurance company wanted to switch one of my patients from Crestor-but we had already tried 4 other drugs-nothing else brought down her TC of 400′s and TG in similar range. (The data is already available in the pharm companies records-the evolution of escalating doses if they looked). I finally get it approved. But now, since she also has RA, she has hit the donut hole.The program for impoverished patients won’t pay for her Embrel until she hits the donut hole, and the paperwork crossover takes a few weeks. We fill out forms for Crestor from the manufacturer-but this has to be done every year.
    Now we get notices that our patients haven’t been immunized (they usually have been, but perhaps at their local pharmacy, so there is not bill that made it back to them). There is no slot for “patient doesn’t believe in vaccines, deal with it yourself, Lord knows I tried” I get the notice for mammogram-why not the gyn that orders them? We are inundated with this stuff. If it were accurate, I would understand-but it may apply to a year ago!
    And DO write that letter, or go to the insurance commissioner. Call your board of consumer affairs. Write your congressman. At least they should be made as miserable as the patients who have to go through with this!

  • Marc Gorayeb, MD

    Why is the bureaucracy insensitive to your needs? Because it can be. If there were a free market for insurance, that behavior would be quickly corrected, because you would complain to them and about them, rate them as is done on many web sites, and then walk away from them when re-enrollment comes around. What you are experiencing is the arrogance of power of a virtual monopoly.

    • Jeff Taylor

      Actually you’d be much better off in Europe or Canada. In the UK, which I’ve just spend some time in, you can fill a prescription from any of thousands of pharmacies for just $10 for any item (and free in Scotland). There are 24 hour pharmacies in most towns.

      Where the free market is also failing is in the manufacture and supply chain – there are shortages of various drugs. We need more government action to secure supplies.

    • imdoc

      I completely agree. We need to separate insurance from employers and the health insurers can answer to those paying the premiums. I didn’t see that in the healthcare reform proposal.

  • Nunya

    Will someone inform the Republicans that rationing of medical care already exists — in all the forms you are experiencing?

    In my case, my insurance will pay for 14 days of (very expensive but 90% cheaper in Canada) oral chemotherapy over 21 days, but only wants to pay for 8 pills per 20 days of the anti-nausea medicine (generic version of Zofran) that I need to keep it down so it will work. This is ridiculous, and the time the oncologist’s office spent arguing with them is a stupid, expensive drain on the GDP.

    End the scare tactics, and give us a decent single-payer system.

    • John Ryan

      Wait a second, the majority of patients that I take care of who experience switch tactics on their drugs or late mail order deliveries are on Medicare! Isn’t that a “single payor system”?

      The problem is third parties (government & insurers) who dictate to both patient and doctor or pharmacy, while keeping an increasing portion of the payment. Get rid of them, pay your own bills, and call your own shots.

    • Smart Doc

      Totally, totally wrong.

      Single payer, or de facto single payer, is the CAUSE of the shortages, not the solution.

      • Jeff Taylor

        No – you’re confusing denial of drugs from an insurer with a shortage of drugs. The latter is a global problem with a number of reasons such as mergers of drug companies, low production of cheaper generics, and currency exchange fluctuations. There is clearly a role to play for government regulation and incentives to secure supplies. Leaving it to the market is causing the shortages.

  • Dr Chris

    I disagree-BC/BS is just as bad-it’s just that those [patients are on fewer meds.

  • Smart Doc

    This has become an everyday experience as monopoly pharmacies are forced on us all: our patients and ourselves.

    And the escalating monopoly pharma is also no longer delivering (lierally) hundreds of essential basic medicines to hospitals.

  • http://Www.jathomas.com Jules Enatsky

    This is not all that unusual Dr. Carroll. Now that many insured must use mail order plans for certain drugs it’s a hole that patients cannot get out of. I take a prescribed Rx for chronic pain & tried to have the new Rx mail order company fill like the last one. This will not happen in Missouri. They don’t allow any scheduled drugs via mail order. I almost ended up in the ED in withdrawal due to insufficient supply. Even if you try & work with customer service it’s without effect since they don’t know the rules.

  • John Driessen RN

    This sounds all too familiar. You are a professional having this problem & you get the same frustration as the patients that get branded ‘non-compliant.’ The insurance companies are @ the root of many medication problems. I have a new patient just D/C’d after a year in rehab for an AKA. Diabetic, HTN retinopathy etc. The rehab facility filled her mess 3 days before D/C using her Medicaid then gave the spouse a handful of RVs that could not be filled until next month. Of course they forgot to tell him this. They also did not give him her mess either. She runs out of test strips for her glucometer & a similar situation happened to her that happened to you. I understand that there must ve rules but this has gotten out of control! Prescribing & distribution of medication & healthcare in general needs to be taken from the bands of big Ins & given back to the medical profession. Prevention is still cheaper than hospitalization!

  • Marie McHarry

    I’ve opted out of mail order (I can with a penalty that I can afford) for all the reasons given. Plus, I firmly believe that it’s important to be able to have a pharmacist who monitors my prescriptions. I go to a small pharmacy in a small town, and I feel lucky that I can.

  • pharmguy

    I am not in any way suggesting that this is a good situation. It is an example of pharmaceutical care at its worst. I cannot and will not defend such deplorable care that this MD is being provided. He and every other patient deserves much better treatment from this or any other pharmacy.

    However, I find it interesting to observe how many physicians are commenting on this situation. I am dealing with a very sick and aging mother, who is at the mercy of physicians offices and is not able to be seen in a timely manner for adrenal insufficiency brought about iatrogenically from excessive corticosteroid use and too rapid of a taper.

    In getting referred to the many specialists (neuro, endocrine, rheumatology), I have yet to get through the bureaucracy and politics of their offices and get an appointment for her in less than 6 weeks. Her PCP wanted her to be seen by endocrine this week. What a joke! Rheumatology told her to wait until June 23, and endocrine told her that their next available appointment was July 11. I called in an attempt to advocate for her to try to get her worked in sooner and got absolutely nowhere.

    In the meantime, she suffers more than I have ever seen her suffer…at home. Weak beyond description, cared for by my 84 year old father. All I get is a ‘sorry’, and weak explanations from appointment receptionists and office nurses defending their practices while telling me how much of patient advocates they are. Meanwhile, she sits and waits…her life slipping away in front of our eyes.

    As a solution, I’ll probably demand that she be admitted to the hospital and have the PCP order all the consults as an in-patient. Suddenly, the very same physicians will have time to see her if it is done that way.

    And while I would never defend this pharmacy’s practices, please stop the ‘aren’t these pharmacies horrible’ tack. Many of your own patients feel the same way about dealing with your offices. This problem is inherent across the entire health care system, yours (and mine) included.

    • http://warmsocks.wordpress.com/ WarmSocks

      The situation you describe with your mother is horrible. Are you saying that whoever wrote the initial steroid prescription won’t renew it? I thought that prednisone didn’t technically require a prescription (like insulin). Maybe that’s just some states.

      fwiw, one can ask to be put on a waiting list in case a doctor’s office has any cancellations. A better solution, where the doctor specifically said “this week” is to enlist the help of the referring doctor. A doctor’s office can usually phone a specialist he’s referring someone to for an appointment that needs to be sooner than the “next available” one that the receptionist will give to patients who make their own phone calls. Next-day vs six-weeks. Good luck!

      • pharmguy

        Thanks! We tried the cancellation route and the MD to MD call…neither of them did anything. My mom was admitted to the hospital last night with a TIA (unrelated to the above problem) and now she will get the consults immediately. That is what it takes to get seen in my area…great system!

  • Molly Ciliberti, RN

    Been there and done that too many times. I wish they would define inconvenience, since this could be life threatening. It is annoying to have someone apologize as if you had an alternative to the situation that you find yourself in. Our state has pharmacists wanting to not fill prescriptions that “violate” their religious beliefs like the morning after pill or birth control (I should note they have no problem with Cialis and Viagra prescriptions and they tend to be male pharmacists.) This pharmacy was unprofessional and did not fulfill their responsibility and there should be some recourse.

    • pharmguy

      In this country, women have the legal right to choose to have an abortive surgical procedure or take an abortive pill. Shouldn’t that right of choice also be extended to health care professionals?

      There are lots of OB docs that do not perform surgical abortions. I have never once heard an outcry or seen a similar post to the one above complaining about that. And yet if a pharmacist (male or female) makes the same decision, there is negative feedback.

      Now that abortion is becoming more of a chemical option rather than a surgical one, shouldn’t a pharmacist be able to decide the same thing as the OB doc, if they have an objection to it?

      All I am asking for is consistency. You can’t have it both ways. A pharmacist is under no legal obligation to fill any prescription. That is pharmacy law 101.

  • JohnH

    I live in Australia and am absolutely amazed at the inefficiency, the unfairness, and what sounds like absolute chaos of your health insurance system. And I’m astounded that you don’t all rise up and revolt! I know I don’t have to tell you that you’re being totally ripped off by companies only interested in making money … I wish you luck with getting a fairer health system.

  • Jackie Schmitt, N.R.EMT-P

    Everything that has been written so far is sooo absolutely true. I have another problem to add regarding the “mail order specialty companys”. Can some one answer the question of “How can these “Pharmacy’s” take a written script from a licensed Physician and change it to the medicine that they perferr?” This has happened to myself and my sister-in-law who’s husband is retired and on his orginal companys insurance plan. This just happens to be the same plan that my husband and myself are on. The two men worked for the same company who is self insurred managed by the infamous BC/BS. I truely think that no only have the mail order pharmacies but the insurance companys themselves are way too powerful and need shot-yes shot down a nouch-no better yet forced to facew up to some kind of truth in practice act on all of the things that they do. We are all doomed if physicians are treated this way without any respect for all of the hard work that they have put in in their training and work. Let the TRUTH be heard.

  • gzuckier

    Yeah, most everybody I know who is forced to deal with mail order pharmacies has a similar story; often a few such stories.

  • Sideways Shrink

    There is a much greater difference in responsibility in the scope of care for physicians and even mid-levels than pharmacists. That is why pharmacists do not get to make this choice. Pharmacists play an invaluable part of the team, but they do not prescribe medications nor should they decide which prescription to fill or not fill. To terminate a patient a physician must give the patient a letter with 1 month of prescriptions and one month of urgent medical treatment–regardless of the pending patient balance. Are pharmacists and their employers willing to take on this level of care for patients?

  • pharmguy

    Sideways – I appreciate your comments. No one doubts that the scope of care by the physician is greater. And yes, pharmacists are an invaluable part of the team as long as we just sit there and fill every order as written. But, the minute we call a prescriber with an “are you sure you want to do this?” call, we are frequently accused of usurping the MD’s authority. The great MD’s to work with thank us for catching the error or discrepancy. The bad ones yell at us and then usually about an hour later we get an order changing it to what we recommended.

    Every single health care professional assesses every order from their area of expertise, and then analyzes it for safety, efficacy and appropriateness. That is the way every health care system works. It’s a necessary double check because the ultimate goal is patient safety. Every single individual along the care continuum has the right of refusal. Stating otherwise demonstrates a lack of understanding of both the law and your fellow colleagues professional responsibilities and obligations.

    In my hospital system, I am a Clinical Manager of Medication Safety. Like you, I also have a doctorate degree in my profession. Of all the med errors that I track, prescribing errors by physicians (usually caught by the pharmacist) are my #1 category. I am thankful that we have a team of very sharp staff pharmacists that catch these things, refuse to fill them and risk getting ripped a new one when they simply call for a clarification.

  • KT

    Take care of you first! Pay out of pocket for one – two days of med – contact your physician in the morning and get a script for a couple of pills for emergencies such as this. Today’s patient is juggling a three rign circus – in ring #1 we have the physician, ring#2 insurance, and in ring #3 retail pharmacies. The patient – unfortunately- while sick still has to ensure that all members of the healthcare team are doing what they are supposed to do so that care and meds are completed. Prepare for the worse – the likelihood of it happening is increasing.

  • Jenn

    This EXACT same thing happened with me. You weren’t, by chance, using Express Scripts, were you? That’s the company that has given me nothing but grief and perhaps an ulcer. I finally had to cancel everything and start all over with them.

  • doc99

    Thank you for this vignette. You have encapsulated the essence of everything that is wrong with our third party payor system – the patient is no longer the client. This presents multiple levels of conflict of interest from which the patient ultimately suffers. Our “Healthcare System” doesn’t need “Reform.” Our Healthcare System needs an Intervention. It really is that simple.

  • katbradley54

    Ahh – the delights of the corner drugstore across the country and your postman as your pharmacist.  Nothing like personal concern and service…

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