Pharmacy problems

[Kooks and Bay Bay]

This is the 3rd time in the past year that me or a family member has needed prior authorization for a medication.

Each time no one told us that. The pharmacy just says its not covered.
It's only after we contact the doctor that we learn oh yeah they need to submit it.
Then we get a call from the insurance company that its been approved.
So we go back to the pharmacy and they just tell us its not covered.
We say yes it is you need to run it through again.
They just stand there and look at us like we are stupid and say no its not covered.
Then we have to call the insurance company and tell them to call the pharmacy and tell them to run it through the system again.
This ends up being a several week ordeal.

Is it just us lol?

 

[TippyThomas]

This is the 3rd time in the past year that me or a family member has needed prior authorization for a medication.

Each time no one told us that. The pharmacy just says its not covered.
It's only after we contact the doctor that we learn oh yeah they need to submit it.
Then we get a call from the insurance company that its been approved.
So we go back to the pharmacy and they just tell us its not covered.
We say yes it is you need to run it through again.
They just stand there and look at us like we are stupid and say no its not covered.
Then we have to call the insurance company and tell them to call the pharmacy and tell them to run it through the system again.
This ends up being a several week ordeal.

Is it just us lol?

Nope. I just recently started some new meds and the process has been a nightmare between the pharmacy, doctors office and the insurance company. The new meds are much more expensive than anything else I've ever taken so I can see why they have the checks and balances, but the process between everyone and getting things done has been a nightmare. Honestly thinking of asking my doctor for alternative so I don't have to keep doing this every month.

 

[_19disnA]

Was it a very pricey drug? I can recall a few years ago something my mom was taking needed some sort of periodic approval since there were other less expensive alternatives. Her doctor had to submit paperwork to the insurance company explaining why those other choices were not appropriate. Can't recall the name of those drugs.

Every insurance company covers different things so I don't necessarily fault the pharmacy for not knowing how every program works. It would be helpful if doctors/insurance companies and pharmacies could work this out among themselves so the patient isn't caught in the middle going back and forth. I would assume most doctors already know which pricey drugs cause these problems, but they seem to act surprised whenever it happens.

 

[Kooks and Bay Bay]

Was it a very pricey drug? I can recall a few years ago something my mom was taking needed some sort of periodic approval since there were other less expensive alternatives. Her doctor had to submit paperwork to the insurance company explaining why those other choices were not appropriate. Can't recall the name of those drugs.

Every insurance company covers different things so I don't necessarily fault the pharmacy for not knowing how every program works. It would be helpful if doctors/insurance companies and pharmacies could work this out among themselves so the patient isn't caught in the middle going back and forth. I would assume most doctors already know which pricey drugs cause these problems, but they seem to act surprised whenever it happens.

Yes I do wish they would just deal with each other instead of me being the middle man.
My main issue is that the pharmacy acts like they have no clue why it wasn't covered even though I've been told by the insurance company it definitely shows the reason. And then when I go back to the pharmacy and they just say not covered and want to move onto the next person and then I tell them it is you just need to run it through again they look at me like I'm an idiot and say that's not how it works... But then when I call the insurance company they say ummm yes that is how it works but we will call them and wait on hold for 30 minutes for you to tell them that.

 

[Mackenzie Click-Mickelson]

It's been a bit since I checked back to see if this was the case still but the pharmacies around me have really been struggling with staffing shortages. This was really bad in 2022-2023 but I imagine it's still bad.

From not filling prescriptions to closing for bulks of the day to entire days to others only taking existing orders instead of new ones for a while so they could catch up.

That said from the pharmacy's standpoint they aren't incorrect at least from what I'm understanding. It's not covered until the insurance company authorizes it but even after the insurance company authorizes it it may not be immediate updates to the pharmacy. Maybe they could be more helpful on their end to ask you questions like "do you know if your insurance company has approved this" or "has your doctor sent the authorization form to your insurance company", etc and then if you responded yes ask when this was to see if you came back too early but given the past couple of years most of them are burnt out and simply unable to take on as much as they used to.

But most of this seems to be on your doctor. If they were doing the proper procedure they would have submitted the request to the insurance company who then passes that onto the pharmacy. If they aren't doing that it's going to cause a problem if you're trying to use insurance to cover the cost of the medication. The doctor should also be the one to tell you if this medication is one that needs authorization each time or if there is a set limit to refills. My sister-in-law is on medication that needs authorization each time though it's a long-term medication meaning she doesn't take it frequently for the listed dosage so it lasts for a long time. Another medication of hers allows for 2 refills before she needs to contact the doctor again to get re-authorization.

 

[Kooks and Bay Bay]

It's been a bit since I checked back to see if this was the case still but the pharmacies around me have really been struggling with staffing shortages. This was really bad in 2022-2023 but I imagine it's still bad.

From not filling prescriptions to closing for bulks of the day to entire days to others only taking existing orders instead of new ones for a while so they could catch up.

That said from the pharmacy's standpoint they aren't incorrect at least from what I'm understanding. It's not covered until the insurance company authorizes it but even after the insurance company authorizes it it may not be immediate updates to the pharmacy. Maybe they could be more helpful on their end to ask you questions like "do you know if your insurance company has approved this" or "has your doctor sent the authorization form to your insurance company", etc and then if you responded yes ask when this was to see if you came back too early but given the past couple of years most of them are burnt out and simply unable to take on as much as they used to.

But most of this seems to be on your doctor. If they were doing the proper procedure they would have submitted the request to the insurance company who then passes that onto the pharmacy. If they aren't doing that it's going to cause a problem if you're trying to use insurance to cover the cost of the medication. The doctor should also be the one to tell you if this medication is one that needs authorization each time or if there is a set limit to refills. My sister-in-law is on medication that needs authorization each time though it's a long-term medication meaning she doesn't take it frequently for the listed dosage so it lasts for a long time. Another medication of hers allows for 2 refills before she needs to contact the doctor again to get re-authorization.

Problem is I don't think the doctor knows until they electronically send it to the pharmacy.
To me everyone is at fault but when I tell the pharmacist that I got the prior authorization approval a week ago and they don't actually run it through the system again its still just gonna be marked as not covered.
They definitely are understaffed but lately they have been filling the meds pretty quickly.
My mom has been on TONS of meds due to cancer and compromised immune system for the past 2 years and hers are always ready quickly.
I also think that the pharmacy industry has seen a lot of retirements and the very new very young staff was not taught the process well.

 

[Mackenzie Click-Mickelson]

Problem is I don't think the doctor knows until they electronically send it to the pharmacy.
To me everyone is at fault but when I tell the pharmacist that I got the prior authorization approval a week ago and they don't actually run it through the system again its still just gonna be marked as not covered.
They definitely are understaffed but lately they have been filling the meds pretty quickly.
My mom has been on TONS of meds due to cancer and compromised immune system for the past 2 years and hers are always ready quickly.
I also think that the pharmacy industry has seen a lot of retirements and the very new very young staff was not taught the process well.

JMO it seems to still falls on your doctor that is causing the actual delay and should be probably even more apparent given your story about your mom, it matches our experience as well too about being ready quick although the most recent I have personal experience with in picking up the meds was back in 2019 for oxy for my mom when she had her total knee replacements so it was pre-pandemic.

When they write a script to you or your family member they then need to submit it to the appropriate party. If for you or your family member that means submitting to the pharmacy first then they should do that immediately which starts the ball rolling to then go to the insurance for approval. Certain drugs may require a different route. In addition looking it up there are also a variety of states (12 on United Healthcare's website) that have specific rules on specific drugs that also require pre-authorization specifically due to them if going through insurance.

I'm looking at United Healthcare (which we have) and it basically states it's from the doctor "Physicians are required to request prior authorization before administering certain drugs covered under medical benefits for UnitedHealthcare Community Plan members, including members who are currently on therapy." As well as "Select medications may require notification and review to determine coverage under the member's pharmacy benefit. Members or their providers may be required to provide additional information to UnitedHealthcare to determine if the medication is covered under the member's pharmacy benefit. The criteria used to determine benefit coverage for the Notification program is based on FDA approved uses of the medication and medication labeling, which look at drug and diagnosis." Now that's just United Healthcare but imagine that's a normal process for other carriers.

Now some drugs may be something someone is paying out of pocket for outside of insurance in which case if allowable insurance wouldn't need to get involved (this would depend on the medication itself).

But I do agree with you if you go back to the pharmacy a week later and explain the issue and request them to run again to see if has been transmitted they should do that. However, to the the pharmacy you're just one order amongst potentially thousands and with the staffing issues and burnt out aspect they may not automatically rerun without you explicitly asking them to do that. I don't know if there is a set time that it updates in their system or if they physically have to rerun it.

 

[lanejudy]

My main issue is that the pharmacy acts like they have no clue why it wasn't covered even though I've been told by the insurance company it definitely shows the reason.

It does show the reason. Your pharmacy should be able to inform you that it needs prior authorization rather than just telling you it was denied/not covered. Is there another local pharmacy you can try for a bit? It sounds like customer service at this pharmacy is a bit lacking.

Problem is I don't think the doctor knows until they electronically send it to the pharmacy.

The doctor should be able to look it up. That said, you should be able to as well. Maybe when the doctor says they are changing your medication you should ask them to check if it's covered by your insurance and/or may need prior auth. And in the meantime I'd double-check any of your existing meds to see if authorization rules have changed. (Usually such changes only occur at the start of the year but it can be at any time. I get a notice whenever the formulary changes for maintenance drugs that we take.)

when I tell the pharmacist that I got the prior authorization approval a week ago and they don't actually run it through the system again its still just gonna be marked as not covered.

My pharmacy only holds a script for a week. If it isn't approved/picked up by then a new script is needed. But again, maybe see if there is a different local pharmacy because this one doesn't seem to want to work with customers.

 

[Disneydawg74]

The pharmacy isn’t usually the problem. It’s usually the prescribing physician that doesn’t comply (because he/she doesn’t know your prescription insurance details). The pharmacy follows what your insurance tells them. I’ve had this problem several times, but it always seems to work out that my physician didn’t do what was necessary. If it happens once, I try to make sure my physician does the necessary paperwork ahead of time. Annoying, yes. But, at least I’m able to get my prescription more easily.

 

[focusondisney]

The doctor should be able to look it up. That said, you should be able to as well. Maybe when the doctor says they are changing your medication you should ask them to check if it's covered by your insurance and/or may need prior auth

Excellent point. Every insurance we’ve had has had a formulary that lists all meds & their different teirs. I am a retired RN. I always explained to my patient s that they need to be the one who knows what their insurance covers. There are so many different insurance companies & each one has many different policies. Most physician’s offices know which procedures & meds usually need pre authorization. But better to be proactive & look it up yourself too.

 

[disneychrista]

I have a prescription that was not covered by my insurance and needed a prior authorization. The pharmacy told me that when I went to pick it up. My doctored had to fill out someone & send it back and it was still denied.

 

[LuvOrlando]

Not just you, happens to me and I get all twisted up until I call insurance.

 

[shh]

This is the 3rd time in the past year that me or a family member has needed prior authorization for a medication.

Each time no one told us that. The pharmacy just says its not covered.
It's only after we contact the doctor that we learn oh yeah they need to submit it.
Then we get a call from the insurance company that its been approved.
So we go back to the pharmacy and they just tell us its not covered.
We say yes it is you need to run it through again.
They just stand there and look at us like we are stupid and say no its not covered.
Then we have to call the insurance company and tell them to call the pharmacy and tell them to run it through the system again.
This ends up being a several week ordeal.

Is it just us lol?

Nope. I specifically told my doc's office I needed a pre auth BEFORE they ran a specialty blood test. Told them during the blood draw - and again after. Tried to do the pre auth myself and my insurer rejected me: has to come from doc's office. Doc's office sent blood draw out to specialty lab for processing. (I even emailed the lab and said to "HOLD until preauth is received from insurance"!)

1. Lab replied to my email 1 week later- "sorry - we already ran your test last week." Then a couple of weeks later, wrote me to say "your insurance company never responded to us".
2. Insurance rejected payment because they said a preauth was never done.
3. Tried calling insurer, doc's office and lab. Got nowhere. Doc's office insists they sent any needed info. Insurance claimed they didn't. Lab says they're not responsible and just ran the tests that were requested by doctor.

This was not a cheap test. It's maddening - there's really nothing I can do except pay the bill. I'm just too tired to waste any more time on this.

 

[EACarlson]

Nope. I specifically told my doc's office I needed a pre auth BEFORE they ran any tests. I tried to do the pre auth myself and my insurer said no - it had to come from doc's office. They didn't do it - yet sent the tests out to the lab. Insurance then rejected payment because there never was a preauth.

These were not cheap tests and it's 100% maddening - and there's nothing I can do except pay the bill. Doc's office claimed they did it. Insurance claimed they didn't.

Sure there is, that's on the doc's office and they should be eating the cost of that test. Happened to my wife with her breast MRI. Health system was supposed to send pre-auth to insurance, didn't, MRI happened, insurance refused to pay, health system tried to bill and then recalled the bill as soon as we called.
It's incumbent on you to know what your insurance covers and make sure any pre-auths are done for prescriptions. The provider is going to make the best medical decision, not necessarily the most cost effective decision for you. If you know what your insurance will and won't cover, it goes a long way to avoiding these issues. I have two prescriptions that require PA, never had an issue with either because I and my doctor knew what we needed to do with it. It does also help that my provider has the same insurance I do.

 

[shh]

Sure there is, that's on the doc's office and they should be eating the cost of that test.

Well...unless an attorney is going to take that case for free, not sure what else I can do at this point? Doc's office will not pay and claims they're not responsible. I've already tried appealing and insurance denied me.

 

[EACarlson]

Well...unless an attorney is going to take that case for free, not sure what else I can do at this point? Doc's office will not pay and claims they're not responsible. I've already tried appealing and insurance denied me.

Keep going up, or force them to sue you for it.

 

[shh]

Keep going up, or force them to sue you for it.

EA - I truly appreciate your suggestions. But if I don't pay, they're going to send the bill to collections. It's not worth that aggravation, not to mention risk to my good credit rating - and frankly, I'm not going to invest more hours suing them in small claims court. It was a few hundred bucks - pricey for a blood test, but not worth all the future time I'd have to invest continuing to fight this.

I'm gonna file it under "life sucks sometimes". I should never have allowed the blood draw without proof of pre-auth - lesson learned. But the doc's office INSISTED that this pre auth was always handled direclty by the specialty lab team - doc sends pre auth paperwork to them, they in turn communicate with insurance. They said they've done this many times for patients. The lab doesn't seem to agree.

The whole thing sounds convoluted to me.
I. hate. healthcare.

Sorry OP: didn't mean to hijack the thread! lol

 

[sheilafri]

Unfortunately, the American health care system is extremely dysfunctional. Incentives are for private insurance to deny coverage.

I have a script for a migraine pill. Old insurance wouldn’t cover the newest iteration as it was expensive. I had to try three rounds of the generic. Relief now takes 45-60 minutes instead of 15. It works, usually, but anyone who has migraines knows that the extra half hour or more of uncertainty is excruciating New insurance said it won’t even cover the generic. For about $1.50 a pill I’ll buy it OOP. Kicker is, they actually do seem to cover the generic! I’m just lucky that I can afford $100 a year if I have to pay OOP.

 

[EACarlson]

EA - I truly appreciate your suggestions. But if I don't pay, they're going to send the bill to collections. It's not worth that aggravation, not to mention risk to my good credit rating - and frankly, I'm not going to invest more hours suing them in small claims court. It was a few hundred bucks - pricey for a blood test, but not worth all the future time I'd have to invest continuing to fight this.

I'm gonna file it under "life sucks sometimes". I should never have allowed the blood draw without proof of pre-auth - lesson learned. But the doc's office INSISTED that this pre auth was always handled direclty by the specialty lab team - doc sends pre auth paperwork to them, they in turn communicate with insurance. They said they've done this many times for patients. The lab doesn't seem to agree.

The whole thing sounds convoluted to me.
I. hate. healthcare.

Sorry OP: didn't mean to hijack the thread! lol

If it's less than $500, it won't show up on your credit report at all. There is currently a proposed rule to remove all medical debt from credit reports, but that will not go into effect until 2025, at least.

 

[tazdev3225]

I get the frustration although thankfully I have a couple of great pharmacists. They actually checked to submit my last prescription through a couple of different payment options and saved me $35. We lost the great coverage we had when my husband retired and the prescription plan we have now is a lot more expensive.

We have an issue with the prescriptions for my husband's custom-made diabetic shoes. He is allowed one pair a year. Medicare says calendar year from January 1 and the only place near me says from the date he received his last pair. We submit the prescription and the paperwork from the doctors that is needed. He is fitted and then we wait. I learned to be very proactive because one year we submitted in April, he got the shoes in early September, and they were fitted wrong. He wound up with an ulcer in his foot and they can be extremely dangerous for diabetics. Thankfully we caught it in time and had weekly foot doctor appointments to get it to heal. The orthotics place blamed the doctors, the doctors' offices both showed me the multiple time stamped transmissions and we waited and they refused to take responsibility. I now refuse to allow them to fit him until they have all the paperwork in their hands and they do not like that at all. He needs a new pair now with a molded brace as his one foot is causing tripping issues. Since we went through the problems last year he didn't get the shoes til the very end of October. They refuse to give an appointment until then which means it will be about 16 months between shoes, maybe longer because of the delays they put us through. I can't afford to pay for them as the shoes cost over $1000 a pair or more. It is frustrating.