After more than two decades in practice, I am still amused by the insurance questions that patients keep asking. I don’t know why patients think that pharmacists should know every minute detail about their prescription plan. In today’s technologically-driven healthcare environment, insurance plan parameters can change from one day, one week, or one month to the next. In addition, with over 4,000 different prescription plans, each with their own “quirks”, all I can say is, “Thank goodness for computers.”
Most recently, I had a verbal exchange with a patient whose plan parameters changed without her being informed of them. She was adamant that the pharmacy was in the wrong, even though her plan priced her refills for her, even though calls were made to her plan to confirm the changes, even though the plan provided verifiable claim data that the pricing was correct. She was sticking to her guns that the pharmacy was wrong because her customer service representative said that there were no changes to her prescription plan for the new year.
In situations like these, where internal conflict exists within and between insurance company’s departments, the insured is left in a “no man’s land” at the pharmacy counter. All the pharmacist can do is to verify the insurance’s copayment and have the patient do some homework on their plan. Most patients don’t know that the customer service agent answering the phone doesn’t know the details of their own prescription plan’s parameters. The prescription processing information, which includes tier structure, formulary requirements, prior authorizations and medication exclusions are handled by either their specific insurance’s pharmacy processor or one that is out-sourced to save the insurance company money. In either case, multiple data sets are fed into multiple databases and all are cross-linked and referenced to issue a specific response to a pharmacy claim submission.
This is why it is impossible for a pharmacist to have the pre-cognitive ability to answer questions on whether a medication is covered or at what tier level the drug’s copayment is programmed into the system. Patients can save themselves a lot of time and stress by taking the initiative to call their insurance company to obtain their insurance plan’s drug formulary. With this document in hand, the patient can take it with them to the physician’s office visit. At the physician’s office, the patient can show the physician the medication choices for the diagnosis and have the physician prescribe from the given list. Any variations from the list will inevitably delay treatment and/or cause added patient expense for treatment. For either situation, delaying treatment or increasing treatment expense can cause additional adverse outcomes in either the patient’s health or financial situation. So, by following the plan’s guidelines, the patient can speed up their cost-effective treatment.
I hope I have given some insight into the prescription processing workflow and what you can do to facilitate a smooth transition from the physician’s office, the pharmacy and to you, the patient.
Until next week, stay healthy.
Dion