The letters are usually four pages long and begin by saying that my patient has received a temporary supply of the medication I prescribed.
Next, there are general paragraphs about how the drug either isn’t on their formulary or the quantity exceeds the plan limits. None of these letters contains a reference to an online formulary physicians can access to compare covered alternatives.
Then there are several cumbersome explanations about the appeal process needed to request a formulary exemption. There are always toll-free numbers to call.
Missing from 90 percent of these letters are mentions of which similar or alternative drugs actually are covered on the company’s formulary. This information is also missing from the smartphone app and website most doctors use to try to avoid these rejection letters – Epocrates, the industry standard for looking up drugs, doses and formularies, doesn’t have access to this information from more than a handful of Medicare D plans.
This presents a choice between a few courses of action for the average doctor:
1. Desperately Google “Medicare D formulary megapharm insurance corporation” (a fictitious insurance company name, to protect this writer from unnecessary litigation), only to end up following links to help consumers choose a plan in their geographic area, and not finding the more or less secret formulary.
2. Switch the patient to the oldest, least effective and least expensive medication in the class, or even in an older generation of generics, and hope it will go through at the pharmacy cash register. This is still not guaranteed to work since the costs of some very old medications have skyrocketed in the past year or two.
3. Have your nurse call the patient to let him or her know they’ll have to pay for the medicine themselves or go without since there is no reasonable alternative.
4. Have your nurse dial up the Medicare D provider, wait on hold for ten or twenty minutes, answer several questions about the patient’s policy number, diagnosis and so on and beg them to reveal which alternative drugs are covered or at least fax over a prior authorization form you can chip away at if there is ever a “free” moment in your day.
5. Make the calls yourself, contain your frustration as you listen to the muzak, see your productivity level and patient volume go down, increase the wait times for patients calling for an appointment, and prepare to see your salary go down after your next performance review.
It is hard to imagine that the Megapharm Insurance Corporations of America are unknowingly wasting paper and postage on these letters that say what’s not covered without advising prescribers which drugs are covered. I am making a very educated guess that the purpose and net effect of these letters is that many patients don’t get the intended prescription, or even an alternate one, thus increasing the company’s profits. For the cost of a single presorted bulk mailing, they can easily save a hundred dollars every single month from this moment forward on one single, hapless victim. Excuse me, “member.”
“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.