Guessing if medications are covered by a patient’s insurance company

One of the frustrating aspects of medical practice is trying to decide if the medication I am prescribing is covered by the patient’s insurance company. Even with the advent of electronic medical records, which should be able to determine this, we are often left to hope and pray.

Here’s how it works. Individual insurance companies have formularies — lists of approved drugs — that they encourage patients and their physicians to use. Of course, this is all about the money. There’s nothing evil about an insurance company making a deal with a particular drug company that gives them a price break. The drug company will be delighted to offer the insurance company a discount in return for an anticipated high volume of prescriptions. You can easily picture an insurance company negotiating with several different GERD medication representatives watching them each lowering their bid trying to get the contract.

Nexium guy: We’ll only charge you $0.67 a pill
Prevacid gal: We’ll only charge you $0.84 a pill and will throw in the Japanese steak knives
Protonix guy: We’ll lower our already rock bottom price down to $0.65 a pill for an exclusive contract
Prilosec gal: We’ll only charge $0.57 a pill for a brief term of 10 years with an option to renew

When a patient sees me for heartburn, and I recommend a medication to ease their pain, often neither the patient or I know which of the 6 proton pump inhibitor medicines (Nexium, Prilosec, etc.) or the generics will be covered. That’s when the guessing starts.

My objective, of course, is that the patient pays the least amount of money without sacrificing medical benefit. When I guess wrong, I am then welcomed by phone calls, faxes and other forms of denial that we then devote time to sort out. Recently, I called a pharmacist with the patient seated before me to try to be a hero and figure out which medicine was the right stuff. Even the pharmacist couldn’t figure it out. She explained to me that she couldn’t price the medicine for this specific patient unless I prescribed it officially and she then processed it through. I thanked her, hung up and resorted to my default strategy. I guessed.

Keep in mind that these formularies change yearly. In other words, a medicine that’s preferred in December may be tossed aside in January when a new drug underbids them. This adds to the adventure. We have an office pool every December when we offer prizes for guessing the new medication changes. We use this changeover as an opportunity to increase staff morale.

Next time you’re in your doctor’s office, ask what a “prior auth” is.

In my practice, I might see 15 or 20 folks each week who want me to put their GERD fires out. They have different insurance plans with different formularies and different restrictions. The chance that I prescribe the preferred medicine to each of them on the first try is much lower than winning the lottery. If fact, if I were to achieve this pharmaceutical tour de force, I think I am entitled to instant wealth. Perhaps, the pharmaceutical companies would pool their resources an sponsor a contest for gastroenterologists. What a slick marketing campaign!

Prescribe heartburn medicines correctly for a week and win a million dollars!

They have nothing to fear. While physicians may accept the challenge with enthusiasm, they will never succeed. They would do better buying a lottery ticket.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower

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  • Patient Kit

    If only we all had the same plan and the same options.

    • PCPMD

      Its sad when that is offered as the better alternative.

      • Patient Kit

        Maybe. But the “gazillion different plans” system isn’t working very well.

    • NPPCP

      Even better – you can check with your insurance company and let me know what is preferred. Then I will prescribe it. I never spend my money tying up my staff doing pre auths. They are forbidden in my clinic. If the insurance company won’t cover a med I rx, I give the patient a list and tell them to call their insurance company and let me know what is preferred – then I write it. Teamwork!

      • Patient Kit

        How does that work? Do your patients leave your office with new scripts, try to fill them and, if they have problems getting them filled at the pharmacy, they call their insurance and then call you with the info about what similar meds their insurance will cover? Is there a lot of phone tag involved? Or do patients call their insurance while they are still at your office to check on whether their plan covers the med you want to prescribe? Thankfully, I haven’t had much experience with my insurance plans refusing to cover a med. Maybe once in the last 20 years.

        • PrimaryCareDoc

          That’s what happens for my patients. If I prescribe something and it’s not on formulary, I have them call their insurance company to find out what is covered.

      • buzzkillerjsmith

        The thing with this is that a lot of the time you have 2 encounters, one at the office and one with the phone call. But I guess a lot of the time this is unavoidable.

        • NPPCP

          Hi Buzz, I would rather make another brief call then fill out a pre-authorization form or pay someone in the office to do it. Those forms are anathema to me. They are forbidden in my clinic unless there is clear justification for the prescribed rx. Hope all is well.

  • Acountrydoctorwrites

    … and only a few insurers put their formulary on Epocrates, the app busy doctors use to check formulary coverage. Medicaid in my state is on there along with a few Medicare D plans.

  • Margalit Gur-Arie

    As far as I know, if you electronically prescribe through Surescripts, you get an automated formulary check (close to real time) that shows not only if the particular drug is on formulary, but also the tier, the retail copay, the mail order copay, and generic or preferred alternatives. This functionality may need to be turned on in the EMR though (ask your vendor about it).
    If all else fails, and these 6 meds are interchangeable, just don’t tick the DAW box and let the pharmacist sort it out.

    • Patient Kit

      The last few prescriptions I got, my PCP seemed to find them in his computer very quickly, asked me what pharmacy I’d like the scripts sent to, he also found my pharmacy very quickly on a long list of pharmacies. You can imagine how many there are in Brooklyn, NY. And by the time I left the hospital a half hour later, I received an email from my neighborhood pharmacy telling me my scripts were ready to be picked up. I wonder if my hospital uses the Surescripts program you’re describing. It was very quick and all three drugs were covered by Medicaid, no problems.

      • Margalit Gur-Arie

        I’m sure they do. Everybody uses Surescripts for electronic prescribing. It is practically a monopoly. It’s got some quirks, but it is pretty good, as far as health IT goes.

        • Patient Kit

          I must admit that I do like electronic prescriptions much better than paper scripts. Very convenient. By the time I get out of the doc’s, my script is ready and waiting for me wherever I want it to be. I like the whole email alert/refill thing with the pharmacy too. Prescription meds is one area in which technology seems to work well. In my experience, anyway.

  • Mark Wheatley

    GERD meds are generally available OTC now, why would there be a prescription written for any of them?

    • Margalit Gur-Arie

      Because without a prescription, OTC drugs are no longer eligible for HSA coverage.

      • doc99

        Glad you pointed that out, Margalit. Nothing like wasting time checking off yet another Rx for Tylenol, another reason why the Affordable Care Act leads to less affordable care.

      • Patient Kit

        I somehow missed this particular change since I don’t have an HSA and I don’t usually take many meds.. But it explains why docs have suddenly been writing scripts for the likes of calcium and ibuprofen lately along with scripts for real prescription drugs. I knew what to do with a script for Percocet. But the calcium Rx is probably still in a pile of paper at home somewhere.

    • LeoHolmMD

      So people can unload the costs of their poor lifestyle choices on others in the same risk pool. Insurance companies only pay when a prescription is involved.

  • LeoHolmMD

    Good post. Patients need to know what is happening in the “market-place”. I think it is actually quite a bit dirtier than what is suggested in the article. Drug companies are using Medicaid and Medicare as government subsidized billboards in order to forge prescribing habits. I was puzzled initially why Medicaid switched its preferred PPI from the initial purple pill to the brand name subsequent one when there was no clinical superiority and the price went up. Brand allegiance was what was actually being purchased. If there were ever a need for a “sunshine act”, this is where it would be.

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