Ask the Pharmacist: Where Can I Complain When I’m Denied a Pain Medication?

Ask the Pharmacist: Where Can I Complain When I’m Denied a Pain Medication?

Most of the people in the chronic pain community have three things in common other than their pain: they are emotionally, physically, and financially exhausted. They are all consumed with fighting their pain and the system that is interfering with them getting proper treatment.

Most want to strike out or sue someone – everyone — from the President to the DEA, Governor, Walgreens, CVS and on down the list. Whoever they believe is standing in the way of them getting the best quality of life they can obtain. All they wish to do is be the best spouse, parent, or employee they can be.

The DEA is putting out public statements that their function is not to interfere with a legitimate patient getting their needed medications. However, their actions and dictates with those in the drug distribution system (doctors, wholesalers, pharmacies, and pharmacists) seem quite contradictory to their public statements.

Drugs SignApparently, the DEA has decided that the pharmacy is the last line of defense in the war on drugs and that it is the pharmacist’s responsibility to determine not only if a prescription is written by a properly licensed prescriber, but also if the medication is medically necessary for the patient.

This requires access to the patient’s entire medical records and a diagnostic skill set for a wide variety of disease states. Which few, if any, pharmacists have! Pharmacists are “drug experts” not diagnosticians!

To date, there seems to be little interest by anyone in the legal community to step up and assist those in the chronic pain community to make the DEA and other bureaucrats take a step back from all of the opiophobic regulations that have been implemented; and all the other players that are interfering with patients getting their necessary medications.

Most of the pharmacists – especially those employed by the chain drug stores – are just employees. Their negative opinion of filling opiate prescriptions are fueled by the “book smarts” that they obtained in college, the indoctrination that the media shoves at all of us every day, and the mandates from their employers. Like trying to avoid being fined by the DEA, mostly for poor record keeping.

If you have some sort of insurance, then you have a contract with that insurance company. You are paying them a monthly premium for them to provide payment to a vendor for a list of medical product and services.

That pharmacist you are dealing with may have never seen the contract between the pharmacy and your insurance company. In that contract, it normally states that the pharmacy cannot charge you cash for a covered prescription and/or refuse to bill your insurance company for your covered prescriptions.

If your drugs are paid for by Medicare Part D or Medicaid, then there is federal money involved.

So there are potentially several layers of contracts involved: the Center for Medicare/Medicaid Services (CMS), your insurance company, the pharmacy and you.

You have paid your premiums as your part of the contract, the pharmacy has agreed to be part of the insurance company’s network, and the insurance company has agreed to be part of CMS network.

If the pharmacy is refusing to fill your prescriptions, then they may be in violation of their contract with your insurance company. The insurance company may also be at fault, for not making their contracted pharmacies live up to the contract. Or the insurance company may be in violation of their contract with CMS.

There are bureaucrats in place to help “make you whole.” First, contact your state insurance commissioner. Here is a website for the National Association of State Insurance Commissioners: http://www.naic.org/state_web_map.htm

If your drugs are paid for by Medicare Part D or Medicaid, here is a website where you can file a complaint: http://www.medicare.gov/claims-and-appeals/file-a-complaint/complaints.html

There may be state level complaint forms for Medicaid. You can your social worker for this information.

These bureaucrats do not come out looking for violations, but they are there to assist you in making sure that all the rules that apply are not violated.

But first you have to file a complaint.

Steve Ariens

Steve Ariens

Steve Ariens is a retired pharmacist and patient advocate who has a blog called Pharmacist Steve. Steve’s wife is a chronic pain patient.

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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On pain meds 4 years. Lost insurance so they said we are taking you off your meds even though I was paying out of pocket. Got insurance back but they will not give me the pain medicine that works. 21 months now a prisoner of my house and countless letters and emails and Dr’s with Aurora, not Dr. shopping, and still no help. 2 pills a day would give me some relief, but OH NO WE CAN’T Give you the medicine that works, but here,,,have some Tramadol.
We all no that will not work. THANK YOU FOR THIS SITE

Ronnie

That’s totally fine if someone was flagged in the system as a doctor shopper etc… getting A LOT OF pain meds. but, IT HURTS THE REST OF US

BL

In Kansas, now Pharmacists can change to dosage of a prescription medication without contacting the dr.

Pharmacists say collaboration bill will improve care-
http://cjonline.com/news/2014-07-07/pharmacists-say-collaboration-bill-will-improve-care

BL

Ronnie, have you read everything that you sign at your pharmacy ? Are you aware of what every word of everything you’ve signed electronically says ? You seem to be thinking that you will be presented with a seperate form and be told exactly what is says and/or what it is for. The next time you go to your pharmacy ask them for a copy of their Notice of Privacy Practices.

Ronnie

The proof is this. It happened, it was unprofessional, it was embarrassing, humiliating, and a violation of my rights. Cvs will not comply or give up their video/audio. The pharmacist will deny he asked that or shall I say ANNOUNCED my health information for everyone to hear, the staff want to keep their jobs. I’ve already spoken to a true pharmacist and a lawyer and regardless of your opinion this pharmacy and pharmacist violated my HIPPA rights. All future visits I will inform them that this is being recorded via my iPhone and/or if someone is with me It will be recorded of video.

Do you honestly think that cvs will admit this ? I’m sharing my story of how this cvs pharmacist labeled me, lied to me about not having the prescription when I know they do, and to top it off yelled/announced asking questions about what am I getting treated for.

1. When the pharmacy tech gave him the prescription – he should have actually looked within the safe that’s under the counter where the regular pharmacist I normally deal with looks and checks. I know/knew they have this in stock as they make sure to have it every month. So him BLUNTLY LIYING TO ME ABOUT A MEDICATION I NEED/HAVE TOTAKE ONCE A DAY, I find to be totally unethical, unprofessional, and plain stupid. He was labeling me without even talking at that point

2. AFTER I TOLD HIM TO ACTUALLY TAKE HIS KEY, OPEN THE SAFE AND ACTUALLY LOOK – what do you know the medication is in stock!! But, a few seconds ago he didn’t carry this medication !!!

3. Once he pulled out the medication, he again while labeling me looks at the prescription, then looks at me and yells/announces ” what are you getting treated for”

If he wanted, needed, or thought anything was out of the ordinary – he should have called my doctor – which I have a contract signed with them NOT CVS !!!!!!!!!

So, stop defending this ignorant pharmacist and just go bother someone else. I KNOW HE VIOLATED MY HIPPA RIGHTS AND BY DOING SO IF YOU THINK HES GONNA JUST ADMIT WHAT HE DID THEN SORRY TO SAY but then your just as ignorant.

BL

The info at the link below is regarding Mass. Pay close attention to what is necessary for a Pharmacist in Mass to fill a rx for Zohydto ER.

After a Draw in Court, Zogenix and Massachusetts Battle Over ZOHYDRO ER May Have to Proceed to a Penalty Shootout Round-
http://www.fdalawblog.net/fda_law_blog_hyman_phelps/2014/07/after-a-draw-in-court-zogenix-and-massachusetts-battle-over-zohydro-er-may-have-to-proceed-to-a-pena.html

BL

Ronnie, let me put it another way. What proof do you have that this occurred ? What do you beleive will happen if you file a federal complaint ?

Ronnie

BL again – per HIPPA laws the pharmacist did not privately take me to the side and ask the questions he announced the question in front if many people and staff and the linked you placed even states regarding written approval. Again your wrong

Ronnie

BL, sorry to inform you but my HIPPA laws were violated

BL

The HIPAA Privacy Rule and Refill Reminders and Other Communications about a Drug or Biologic Currently Being Prescribed for the Individual-
http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/marketingrefillreminder.html

Kurt W.G. Matthies

Doesn’t HIPAA protect my from a pharmacy requesting my medical information, like my diagnoses?

Ronnie

a HIPAA violation would have occurred if the conversation – which included your PHI ( Personal health information) in a place, manner, sound level for others to overhear. A Pharmacist is a healthcare professional and has the right to – politely – discuss your health issues .. as long as it is a private conversation.

FYI : this was not a private conversation. Via this is a HIPPA Violation

BL

Pharmacists are allowed to ask what you are taking medications for if there is not a diagnosis code on the rx. The Pharmacist could have called your drs office and asked the same question but it may have been several hours or the next day before you could get your rx. The reason I say several hrs or the next day is because chances are someone would have to have called the pharmacist back and given them that info & it may have taken that long for them to do it,

Ronnie

I agree totally with Pharmacist Steve. Pharmacies and the Pharmacist are one of the issues here. Just on 6/26/2014, I walked in with my regular script and it just so happens that day there was a different pharmacist. The tech brought him the script and asked ” do you have this in stock” The pharmacist said no (didn’t even look). I know they carry this, because the main pharmacist keeps this in stock for me. I informed him to take his little key and bend down and open the safe and look. Guess what….

The medication was there!!!! Then, he looks at me, looks at the medication/prescription and announces from the middle of the room and I’m standing where you drop off scripts ” WHAT ARE YOU GETTING TREATED FOR”

1st – If he really wanted to know, I have a contract signed through my PM office, he should have called and asked. I do not have any contract signed with CVS for him to ask a personal health related question.

BL

Sari, Medicaid & Medicare Prescription Part D are cracking down in pain meds. So making a complaint to either won’t get you anywhere. There is no defination for overutilization, it is up to the individual looking at your case. With Medicaid, they go after high prescribers of pain and other specific meds.

Medicare Part D Overutilization Monitoring System-
http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/HPMSmemo_MedicarePartDOverutilizationMonitoringSystem011714.pdf

Grassley Probes High-Volume Medicaid Prescribers-
http://www.medpagetoday.com/PublicHealthPolicy/Medicaid/30857?utm_medium=email&utm_campaign=DailyHeadlines&utm_source

Sari

I use a national chain of drug stores so that I can get my meds anywhere (they share files online between stores). I have a very complex medical and surgical history (including, amongst other things but which are relevant to this story, Crohn’s Disease, Complex Regional Pain Syndrome and an inability to fight off multiple staph infections due to my weakened immune state), and I felt reassured knowing I could travel around the country and still have my records and medications accessible. Three years ago I needed emergency surgery on my index finger bc I had a massive cellulitis/staph infection that was spreading due to a combo of my compromised immune system, a medication I was on for my Crohn’s, and pricking my finger while planting flowers (how pathetic is that, lol). When I was released from the hospital I was planning to stay with my fiance’s parents, and so I immediately took my scrip for pain meds (and antibiotics) to the chain store I use that was closest to them, finger and hand all wrapped in gauze, hospital bracelet still on and all. The guy at the pharmacy counter– who couldn’t have been older than 21– looks at my list of meds online (which includes, to this day, methadone for pain control) and says “I’m not filling this: based on what I see here you are an obvious continuous drug user, and possibly an abuser and a drug seeker. I have the right to refuse to fill any prescriptions I think are problematic; please leave this store or I will call the police.” Needless to say I freaked out. I asked to speak to his manager, but that was him, and there was nobody above him available. So I pulled out my list of diagnoses, surgeries, doctors (including my pain care management specialist who was involved and on board with every decision), meds, etc, and asked him to read it while I unwrapped my swollen, stitched finger, then shoved it in his face and asked if he STILL thought I was a drug seeker. He still refused to fill it, although at that point I think it might have been to save face bc we were attracting a crowd of people who were both waiting on line for their meds and just nosy. I asked him what schooling and training he had as a pharmacist, which not surprisingly wasn’t much, and then asked him if he REALLY thought HE knew better than a surgeon who spent 10 years in school for his specialty and who worked at one of the top teaching hospitals in the state. At this point he got flustered and again threatened to call the police. I told him to go right ahead bc once they saw my evidence they would laugh him right out of the store. He didn’t call, but still refused to fill my scrip, and at this point I was so steaming mad and upset that my fiance was worried about my… Read more »

BL

Nancy Adams, often New Patient forms have a place that states you give permision for your dr to discuss with other health care professionals about your care. Pharmacists are helth care professionals. Most people don’t pay attention to alot of the things they sign when they see a dr for the first time, let alone remember it on down the road. Your insurance company may also have the same rights. Sometimes, we don’t have to sign anything, we agree to it by using services, like insurance.

CT

melvis, check into Angel Flight. For your area it is probably Angel Flight Northwest. They will fly patients, for free, that are in need of transportation for medical care/appointments. They are an organization of pilots that donate their time, aircraft & money for gas. You have to have a medical need (travel by car is stressful) & possibly a financial need, not positive about that part though. They are truly angels. Let me know here what you think.

John S.

But didn’t the u.s. just grow the largest bumper crop of opium in history in afganersten . must be slated for the street . more profit that way .

Nancy Adams

How could the pharmacy see my medical records?? Don’t I have to give permission? I thought that was what HIPA was for?

This is it in a nutshell:
“To date, there seems to be little interest by anyone in the legal community to step up and assist those in the chronic pain community to make the DEA and other bureaucrats take a step back from all of the opiophobic regulations that have been implemented; and all the other players that are interfering with patients getting their necessary medications…” BAM!

This is what we said before, over and over. I believe it was after the DEA came out and said it wasn’t their fault! If you look at all these ridiculous laws and rules, it only adds obstacles to the “good, old fashioned doctor/patient relationship. The pharmacy has nothing to do with this except to fill the script. That’s all! Fill the script.

The thing about there not being enough meds to go around has already been traced back to the DEA. They are pressuring everybody. This is their desperate attempt to keep their jobs. They lost the War on Drugs years ago. Now it’s the “War on people!”
Time for them to be fired. I got fired because I got sick. Shouldn’t they be fired for not doing their job or for being unnecessary?

It always comes down to us, the sick people. I guess this is why we get picked on so much. We’re an easy group to go after. When the time comes for us to take action, most of us can’t! How bad is your group when you have to pressure sick people to prove you’re needed? Well , DEA, you’re not needed! We are the legitimate majority by far, and we don’t need you. Thanks for your help, now get out!

Think about it, the whole medical system – doctors, lawmakers, insurance people, employers and patients. How many of the others have given patients a hard time? All of them! All of them! And which group did the patients give a hard time to? Unless you call “being sick” giving someone a hard time, then, no one! not a one! So why pick on us?

Because we probably can’t fight back! Like Pharm Steve said in the quote:
“…by anyone in the legal community to step up and assist those in the chronic pain community to make the DEA and other bureaucrats take a step back…”
Never has been…why start now?

Scott Mitchell

After being treated like a junkie be Walgreens,i was lucky to find a mom and pop…IN FLORIDA.Who does order once a week.Not even gonna bother to list all my conditions.The fact is I always hear of, or meet someone who is in worse shape then me……in my case it was definitely the head pharmacist at Walgreens who made the call on me,after providing my legally prescribed pain medications for 4 years.About 4 months after they got hit by the DEA with a measly 80 million dollar fine.It was 1 or 2 months later, after i spoke up while in line, that they were “short”,then eventually”couldn’t get them.Larry at the store in Jupiter ,FL was complaining about it.”GOOD ,I SAID.You guys were providing all the pill mills”Larry’s store was the TOP 100 walgreens ,in the USA,filling scripts.Heis in my mind, a big hypocrite. A licensed dealer.By the way i have Medicare,but gave up trying to complain,can’t stand being on hold for hours,.And i have one of the most respected pain management DR.in Palm Beach County.A stand up man!

@Kurt.. some of the pharmacies don’t have enough inventory because the DEA has strong-armed the wholesalers into rationing the amount of controls that a pharmacy may purchase. There are three major wholesalers that control 80%-90% of the market.. So – IMO – the wholesaler is the genesis of the ADA violation of chronic pain pts not getting their meds.. Simply get a letter from the Pharmacy/Pharmacist that the wholesaler is rationing their purchases which causes them to be unable to fill your Rxs.. which should be your proof to file ADA complaints against the wholesaler

@John .. I am sorry that I am informing pts that pharmacists are profiteering off of chronic pain pts.. demanding that they pay cash to get their meds.. when the pharmacy has a contract with their insurance company.. or refusing to fill a valid prescription for some bogus reason.. Maybe some pharmacists consider such actions ethical.. I , for one , don’t… Pharmacists who obey the laws and take care of pts.. have nothing to worry about.. If some/many/all chronic pain pts elect to do nothing.. then pharmacists will be allowed to keep violating the laws… and those in the chronic pain community will continue to suffer and be at the whims of Pharmacists.

@BL depending on how the pharmacy orders their C-II’s.. if they use a process referred to as CSOS.. they can electronically order the C-II’s and they will be delivered next day Tues- Fri. If the store still uses the old Form 222 there would be a extra day involved in getting a order.. if whoever has authority to sign the forms is working on that particular day.

@BL all pharmacies are required to keep a perpetual inventory on all C-II’s.. It would be very easy for a auditor to look at that inventory for a given day to see if the store had inventory.. it would also be easy to see if the pharmacy filled a Rx for a particular controlled med by going thru the paper Rxs or computer printout for a few days of either side and/or invoices of purchases.. IMO.. it would not take more than 30-60 minutes or less of audit time to come to some certainty that the store had inventory on hand.

melvis

I feel awful for those of you having to deal with this mess, especially Florida seems to be the worst anti pain patient in the country. Living in WA state, we have an alternate now with legal marijuana, it’s a blessing when your suffering and need relief.
We do have another problem here, which is an anti opiate mentality amongst health care providers. They just flat refuse to prescribe them, no matter what your pain level or cause of pain is. I had a 2 level ACDF surgery, my second spinal surgery in 4 years, and my surgeon gave me 30 percocet upon my discharge. I was like, “thanks for nothing” . Thank god my primary MD in Nevada isn’t afraid to treat his patients, so I was treated by him instead. The sad thing is the costs to travel there, but at least I have a great doctor.
The laws need to be more patient rights focused, and less punitive for providers who are giving relief to this population of pain patients.

BL

If the pharmacy is out of the medication, they have to order it. Schedule II meds aren’t ordered like regular meds are, they are delivered once a week. Someone would have to take a rx in before they sent the regular pharmacy order in, even then there is no guarantee that the meds ordered would be in the delivery that came in in a few days. Schedule II orders can’t be called in so the patient would have to contact the dr and pick up another rx, Some drs make it easier than others.

This will be another problem people who take hydrocodone combination meds will encounter when they go from a Schedule III to a Schedule II.

John

Promoting patients to file complaints against pharmacists is the biggest sack of bull**** I have ever seen regarding the whole issue of pain sufferers and pain medications. The fact you were a pharmacist is very disheartening.

Kurt

Too often in the last year, pharmacies have not had adequate quantities of pain medication in stock, and laws on controlled substances prohibit splitting a prescription into parts.

I never did understand this rule — if I receive 60 pills today and 60 pills next week, how does this foster drug diversion?

In many states, pharmacists have a 72 hour rule, meaning they can fill partial today and the rest within 72 hours, however, I’ve never known a pharmacist who would offer to fill most today, and get the rest by Thursday.

Pain patients bear the brunt of this administrative burden by having to “pharmacy surf” to find adequate supplies, often in violation of our controlled substance contracts.

BL

Making complaints are fine. But, when it comes down to it, I don’t see the pharmacies being made to fill pain meds. There would have to be proof that they had the correct medication, dosage and quanity in stock at the time the person was at the pharmacy. The pharmacy can say they didn’t have what the prescription was written for or that the patient didn’t come to that location. The pharmacies would have to be fined and/or sued and that won’t happen.

Same thing if someone is receiving SSDI or SSI, and are denied pain meds. Them trying to file a suit based on the ADA won’t happen because no attorney would lake it because they know it can’t be won.