Ask the Pharmacist: Can My Insurance Help Get a Prescription Filled?

Ask the Pharmacist: Can My Insurance Help Get a Prescription Filled?

Dear Steve,

Pills as question on white isolated background. Medical concept.What recourse does a patient have if every pharmacy that they go to refuses to fill their scripts? Pharmacies where we had prescriptions filled for over 2 years are now refusing to fill legitimate scripts provided by our pain management doctors.

My wife had to visit the emergency room 3 times last year at great cost to us retirees because of withdrawal symptoms from pain medications.

I talked to my insurance provider about the situation and they said that they would like us to report the contracted pharmacy back to them so their legal department could take care of it.

Stephen G. from central Florida

Dear Stephen,

I am glad that your insurance company wants to get involved. I have not heard much about insurers taking an interest in pharmacies refusing to honor the terms of their contracts. But that could be changing.

There is a five star rating system that is being expanded in the Medicare Advantage program starting in 2015. It now applies to Advantage/Part D providers. If insurers and pharmacies lose enough “stars” due to complaints or other customer service issues, it will affect their level of reimbursements from the government. If they lose enough stars they risk being thrown out of the program.

In theory, the initial focus is supposed to be on medication compliance by patients with chronic conditions such as diabetes, high cholesterol and high blood pressure. But managing a patient’s chronic disease states should be across the board for all disorders – including chronic pain.

Your insurance company is accepting premiums to provide you with certain services and products. That insurance policy is basically a contract. If you can’t find a pharmacy to fill your prescription, then you need to tell the insurer that they are not meeting the terms of your insurance contract and that you will file a complaint with the state insurance commission and the Centers for Medicare and Medicaid Services for insurance fraud.

Tell them that they need to find you a local pharmacy – in their network – to fill your prescriptions.

If you feel you are being discriminated against because of a medical condition, that is a civil rights violation under the Americans with Disability Act (ADA). Click here to file a complaint with the ADA. You don’t need an attorney to file a complaint.

In my opinion, what you are experiencing is discrimination under the ADA: patient/senior abuse and denial of care. Federal and state agencies should go to bat for you if you file complaints.

If for some reason they do not, I would contact the local investigative reporters of TV stations.

Steve AriensSteve Ariens is a pharmacist and patient advocate. Steve has over 40 years’ experience as a pharmacist in Indiana and Kentucky, and has served on the board of directors of the Indiana Pharmacists Alliance and on steering committees for the National Community Pharmacists Association.

Steve’s wife is a chronic pain patient. You can learn more about Steve by visiting his blog at Pharmacist Steve.

If you have a question for Steve, send it to AskthePharmacist@nationalpainreport.com.

The information in this column is not intended to be considered as professional medical advice, diagnosis or treatment. Only your doctor can do that!  It is for informational purposes only and represents the author’s personal experiences and opinions alone. It does not inherently or expressly reflect the views, opinions and/or positions of National Pain Report or Microcast Media.

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Coonhound

rk says:
How can that medicare map be right when florida is supposedly the worst and where all this started how can they have almost the lowesr percentage of opioid users?

rk, this study and accompanying map was in reference to Rx opioids filled in 2011 by Medicare patients only. Remember that a high number of opioid Rx meds were from ‘pill mills’. These disreputable establishments filled most of their Rx on site and accepted neither Medicare Part D nor private insurance but by cash payment only.

The 32% stat of Medicare patients take at least one opioid rx per year?
I find that stat to be pretty low IMO considering it is our disabled and elderly citizens. I would expect it to be much higher.

What is scary is the new ‘cut offs’ that could lead to a Medicare Part D beneficiary being ‘locked in’ and able to use only a single pharmacy or single prescriber for all their controlled meds. The cut off for opioid Rx per year is 23 (many legit PM clinics issue 24 per patient per year one per month of a BT med and an ER med). Another is using multiple pharmacies to fill your Rx. Somehow it is the patients fault for using numerous pharmacies. The real reason is legit Rx refusals (even from long time patients w/ documented disease states known to cause pain) out of stock for ‘narcotics’, and price gouging by independents who refuse to fill Rx for insurance customers taking cash only, basically legalized drug dealers. Lastly you may be targeted as an abuser if you had too many docs write you an Rx for controlled meds. [Having two surgeries(PM doc agreed to let surgeons write post op meds for convenience), refusal of service despite pharmacy contracts violations (see my comment below), and one ER Rx (approved by PM doc) give me ‘red flags’ in ALL areas indicating potential abuse.

Ethics and Trust?
No matter how these issues are ultimately resolved I would be surprised if, in future questionnaires and surveys; docs and pharmacists still rate as highly on honesty and ethics.
I believe the past few years have created a DISTRUSTING environment that could take decades to repair.

If more had a spine and would work WITH each other and their patients, the DEA would have their work cut out for them, as it is now, they cast aspersions upon each other rather than banding together. They play into the DEA’s hands as they and boot licking State Medical Boards both pick out a few in each state (Dr Ibsen) and make an example out of them. This forces the rest to work in an environment of fear and intimidation which puts them on the defense (for their license and livelihood) rather than putting their patients health as their main priority.

rk

How can that medicare map be right when florida is supposedly the worst and where all this started how can they have almost the lowesr percentage of opioid users?

BL

Medicare Prescription Part D Plans have new ways and are looking for more to crack down on opioid use if it is not cancer related.

“In 2015, prescribers will be required to enroll with the Medicare program to be able to write a Part D-eligible prescriptions. In addition, CMS plans to implement predictive analytic tool to assess fraud and abuse risk of prescribers and pharmacies based on an analysis of Part D’s prescription drug data.”

Opioid use among Medicare Part D enrollees-
http://www.medpac.gov/blog/october-2014/october-2014/2014/10/22/opioid-use-among-medicare-part-d-enrollees

Brenda Alice

Steve, once again you come to our rescue. Thank you. I spent 3 hours on phone yesterday with 3 different answers with Caremark about the sudden need for pre-authorization of my narcotics. For the first time the doctor’s office was helpful. I appreciate your links for help on your blog and love the clip you did by Ken so much that I put it on my timeline for others to see that is educational and touching that all should see. http://www.thepetitionsite.com/takeaction/891/682/672/ for the petition and please see Steve’s blog for this awesome clip. I would volunteer if a attorney could be found. I am so tired of the discrimination and having to go every 30 days to the pain clinic and pray that the medication is filled.

BL

“Americans have said nurses have high ethics and honesty. Two other medical professions — medical doctors and pharmacists — tie this year for second place at 65%”
http://www.gallup.com/poll/180260/americans-rate-nurses-highest-honesty-ethical-standards.aspx

rk

Sure seems like discrimination to me or at least violating the adults w disabilities act.

BL

rk, you’re right. Just because someone files a complaint doesn’t mean anything will be done. The reason lawyers won’t get involved in suing for discrimination is because it is not discrimination. Most people just want to think it is because it gives them something else to complain about. They can’t comprehend the ADA.

Coonhound

StephenG- I am sorry to hear of your troubles attaining needed medicine. Over the past year I have experienced the same problem. I am a disabled citizen w/ two systemic autoimmune diseases known to cause chronic pain. I was diagnosed and received referrals to pain management from the prestigious institutions of Johns Hopkins University Hospital and Baptist Medical Center. Since July 2010 I have received comprehensive treatment w/ a well rounded treatment plan, not just opioids, w/out any problems (red flags) by a PM clinic located on the grounds of a major medical center. I felt pretty secure and up until April 2014 had no problems attaining my scheduled meds despite all the collateral damage caused by the DEA’s war on the ‘prescription epidemic’. After 4 yrs filling my Schedule II meds (no dose changes or early/lost fill requests), I was ‘assigned’ to one of the medical center’s 7 pharmacies despite fact that all were open to the public and ‘in-network’ for my Plan D Rx plan. If this particular one happened to be out of my medicine I could not use another and was on my own. I asked to see where this policy was is writing and have never received anything. I called the hospital’s patient services and talked to a patient advocate who referred me to their director of pharmacy. She did not return messages so 3 days prior to my upcoming appt and running out of meds, I had to get creative (called her assistant who said oh she’s right here). She apologized and said DEA was limiting amount of meds they get and were watching ‘everybody’ like hawks. I called her out on these and many other excuses she tried to use in defense of the mistreatment I was receiving. I called B/C B/S and reported the pharmacy PIC and the director for violation of contract as stated in my Explanation of Benefits package. This booklet explains what you are entitled to as a member of a carrier’s Medicare Part D Rx plan. I was told a grievance would be filed and I would hear back w/in 30days. After speaking w/ B/C B/S rep about Rx coverage on another medication I asked the rep to check on the status of my grievance as it had been past 30 days. Nothing showed up on my profile but rep promised I would receive a call regarding this issue in the next day or two at the most. After 3 days I reported them to CMS for violation of contract. The CMS rep seemed disinterested in helping me so I demanded a supervisor. Supervisor @ CMS seemed to think I was definitely being discriminated against because in needing a Schedule II med I was restricted to 1 of 7 pharmacies. In EOB it states that at ANY in-network pharmacy they need to fill ALL medication listed in their formulary (except in case of drug interaction, etc). Ironically I received a call 2 days later from B/C B/S. It… Read more »

rk

This has been going on for over 2 years and its only getting worse and worse, obviously nobody cares and these complaints havent been doing any good either. If it is discrimination, then why wont any lawyers sue any of them?