Having good relationships with pharmacists

[SClENCE]

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The issue is between the PATIENT and the INSURANCE and only the DOCTOR can fix it.

Yet it's the pharmacies fault. Would you rather receive a fax or 67 phone calls from your impatient patient?

I agree, people should take responsibility for their own insurance but lets be honest here the average person has the IQ of a potato and must be spoon fed through every issue THEY run into with THEIR plan.

 

[504poboy]

I try to answer phone calls ASAP from pharmacists and they appreciate it. I know you guys are under a lot of increasing pressure, metrics etc.
I try to be nice and reasonable.

Why do the insurance companies prescription plans try to put the patient on 3 month supplies within the first or second prescription? I am trying to adjust medications and cannot start people on 3 months of meds at that time.

I found some prior auths are ridiculous. One sends me a full page with nothing filled out on it. Then after that, they send me a second one for the specific medication. It's ridiculous. How do you think is the best way to handle these as I know this slows down the works for you guys too.

These pharmacy discount cards "Free USA " cards and the such. Cards with the American flag, etc are helpful for patients, but I looked over some threads here and I'm still not sure about the marketing, data mining, etc and if this is good for patient privacy. The cheaper lists at Walmart too have a notation that their information is utilized...

I hope other people put more questions on here too.
Thank you for your consideration.

I got the answer for you Grover. 1st of all let me tell you that I used to work work CVS CAREMARK prior authorization division. There are problems with these insurance companies. They do not want to pay for brand name drugs end of story. There are 3 tiers to Health Insurance in regards to prescription drugs. Some insurances only have 3 or 4 depending on the PBM.

Formulary Nonformulary
1. preferred generic 1N Nonpreferred generic
2. preferred brand 2N Nonpreferred Brand
3. preferred specialty 3N Non preferred specialty

If you decide to go straight to #2n without trying 1 or 2 first, it will get denied. In order to get there, the patient MUST try and fail ALL formulary items #1 and #2 items, before they can get approved for a "nonformulary item".

 

[PikminOC]

I got the answer for you Grover. 1st of all let me tell you that I used to work work CVS CAREMARK prior authorization division. There are problems with these insurance companies. They do not want to pay for brand name drugs end of story. There are 3 tiers to Health Insurance in regards to prescription drugs. Some insurances only have 3 or 4 depending on the PBM.

Formulary Nonformulary
1. preferred generic 1N Nonpreferred generic
2. preferred brand 2N Nonpreferred Brand
3. preferred specialty 3N Non preferred specialty

If you decide to go straight to #2n without trying 1 or 2 first, it will get denied. In order to get there, the patient MUST try and fail ALL formulary items #1 and #2 items, before they can get approved for a "nonformulary item".

Thank you. I write for cheap generics. They want 90 off the bat. Not happening.

 

[PikminOC]

He doesn't have office staff, so he's stressed from doing their job and his own. Pharmacists who are stressed from not having enough tech hours don't get to make the choice; they're stuck with what corporate will give them. He actually has the opportunity to fix the situation, but he won't.

im not paying someone to deal with this garbage. Why would i pay someone for that? Workmans comp etc? If i pay someone it will be a revenue generator. Not to deal with this.

 

[PikminOC]

The issue is between the PATIENT and the INSURANCE and only the DOCTOR can fix it.

Yet it's the pharmacies fault. Would you rather receive a fax or 67 phone calls from your impatient patient?

I agree, people should take responsibility for their own insurance but lets be honest here the average person has the IQ of a potato and must be spoon fed through every issue THEY run into with THEIR plan.

i already coach my patients ahead of time. I'd rather hear from them.

 

[drcrispmd]

The best part is that often the drug that requires the PA isn't any better than the covered medication. It's just the doctor likes it when the sales rep come in and flirts with them. Makes them feel important

Agree. I almost never do PA unless patient had been on the med for years are is stable or there are no alternatives. I was a tech in undergrad and one of my duties was reminding doc to respond to PAs (sometimes taking several weeks for them to do anything). Makes everyone's life easier.

I have one pharmacy in the small town my clinic is located which is great. They are always very nice when I call regardless what it is about. If they don't have something in stock (like eye drops) they will call quickly and tell me what they have that is also usually covered. Another pharmacy in town is not the same. I call which a question about a patient's prescription and always put on hold forever. They wait to call with any issues with the prescriptions right before we close (even though the patient was seen that morning). They refuse to check the hold file before sending multiple faxes the same day for refills (I try to make sure my patient has refills to get to next appointment). When something needs a PA they never give us the pharmacy help desk number (we have no clue what drug an they have). It is completely different dealing with them compared to the other one.

 

[504poboy]

Thank you. I write for cheap generics. They want 90 off the bat. Not happening.

Alright....so the reason why the insurance companies outright want you to do a 90 day supply is that....it's cheaper for them to do a 99 day supply than a 30 day supply.....they don't have to pay the administration fees each month....there's something called a dispensing fee in the formula for reimbursing an rx....all my independent pharmacy owners know about this when they sign their contract....the ones that work at chains are not very familiar with how the insurance game works....a lot of them don't even know the formula for a prescription reimbursement...they usually are like "I'm too high and mighty to deal with patients insurance problems"....let me give it to my senior tech....what are you going to say when you're super tech calls in sick....they usually say I'm short staffed or an easy cop out...it's not covered...they didn't even bother to even touch the claim....every time a prescriptions is submitted to the insurance....the person on the insurance side can see what claims got denied and see why....they have error codes....

I also don't know if you deal with Medicare patients. This will help as a guide. These are how all the rules are and determined for Medicare Part D and some commercial insurances.

http://www.medicarepartdappeals.com/PrescribersPharmacists/FrequentlyAskedQuestions.aspx

Now you can file a complaint(grievance) with Medicare. There are only 2 people in the world that can file a complaint (grievance) with about the insurance
1. patient
2. Provider

Pharmacists and technicians are not allowed to file a grievance. These are rules made by this organization up above with CMS. Can you please spread the word to other healthcare providers about this? If someone can create a company and compete with Maximus. You will get cool points in my book. If you can file a grievance, this affects a health insurance's stars ratings. This whole thing is all Effed up. The sad part is that pharmacists see this everyday but we can't file compaints on their behalf

 

[504poboy]

https://www.cms.gov/Medicare/Appeal...gApplGriev/downloads/partdmanualchapter18.pdf

All insurance companies have to follow guidelines made by medicare of "chapter 18 of the medicare Prescription Drug Benefit Manual. If you are weary of downloading the above link, please google "medicare prescription drug benefit manual chapter 18"

 

[PikminOC]

Alright....so the reason why the insurance companies outright want you to do a 90 day supply is that....it's cheaper for them to do a 99 day supply than a 30 day supply.....they don't have to pay the administration fees each month....there's something called a dispensing fee in the formula for reimbursing an rx....all my independent pharmacy owners know about this when they sign their contract....the ones that work at chains are not very familiar with how the insurance game works....a lot of them don't even know the formula for a prescription reimbursement...they usually are like "I'm too high and mighty to deal with patients insurance problems"....let me give it to my senior tech....what are you going to say when you're super tech calls in sick....they usually say I'm short staffed or an easy cop out...it's not covered...they didn't even bother to even touch the claim....every time a prescriptions is submitted to the insurance....the person on the insurance side can see what claims got denied and see why....they have error codes....

I also don't know if you deal with Medicare patients. This will help as a guide. These are how all the rules are and determined for Medicare Part D and some commercial insurances.

http://www.medicarepartdappeals.com/PrescribersPharmacists/FrequentlyAskedQuestions.aspx

Now you can file a complaint(grievance) with Medicare. There are only 2 people in the world that can file a complaint (grievance) with about the insurance
1. patient
2. Provider

Pharmacists and technicians are not allowed to file a grievance. These are rules made by this organization up above with CMS. Can you please spread the word to other healthcare providers about this? If someone can create a company and compete with Maximus. You will get cool points in my book. If you can file a grievance, this affects a health insurance's stars ratings. This whole thing is all Effed up. The sad part is that pharmacists see this everyday but we can't file compaints on their behalf

Correct. Not my problem regarding what the insurance company wants. If the patient overdoses on the med, will the insurance co be liable? I think not.

 

[504poboy]

Actually it is your problem. You're a lazy MD in regards to finding a solution to your prior authorization problem. You come on the pharmacy forum to complain about you have to do more paperwork. I have clearly shown you what the solution is and you reply back with "If the patient overdoses on the med, will the insurance company be liable? If you are worried about liability issues, you need to get a lawyer not a pharmacist. Or you need to need get more Professional Liability insurance. I would tell your patient, I recommend finding another physician.

 

[Prepharm1214]

You need to hire more staff and until then you seem to insist the problem lies elsewhere. Third party payment has changed a lot of the years and unfortunately this leads to more paperwork and barriers for your patients, this seems to be giving you a lot of stress and would be worth the investment so you can focus your efforts on 'direct patient care'. Direct patient care will only go so far if your patients can't get their medications because your office isn't following through on paperwork only they can complete. While this thread seemingly started off with good intentions it has morphed into anything but.

 

[Member 5149]

You know some conspiracy theorists will say the PBMs make things difficult b/c they're ultimately trying to control how the physician prescribes in order to ensure more money in their pockets and the drug companies.....

Mmmh... yes, let's have everyone gang up on the physician (patient, technician, pharmacists) so that once they're beaten to a pulp with paperwork and angry patients they ultimately give in..

Sounds like a good plan to me

 

[PikminOC]

Update:
Interestingly, for one patient, I did complete the pa on quetiapine in front of them so they know what we have to go thru for it. It wasn't accepted as I gave sixty pills of 25 mg and the plan would only give forty two. Oh well.
I do appreciate the pharmacists who post on here who are not giving ad hominem attacks.

 

[Jibby321]

Update:
Interestingly, for one patient, I did complete the pa on quetiapine in front of them so they know what we have to go thru for it. It wasn't accepted as I gave sixty pills of 25 mg and the plan would only give forty two. Oh well.
I do appreciate the pharmacists who post on here who are not giving ad hominem attacks.

Could you do #30 of 50mg and have the patient cut them in half? That way they have a 30 day supply. I'm assuming the prescribed dose is 25mg bid?

 

[PikminOC]

Could you do #30 of 50mg and have the patient cut them in half? That way they have a 30 day supply. I'm assuming the prescribed dose is 25mg bid?

I would have to go thru the whole rigamarole again. And I was titrating, so the patient was supposed to take one half to two of the twenty fives qhs.
This is why we get annoyed. Such a waste of time and the patient needs the meds asap.
I called one company for a PA, and they said it would take seven to fourteen days to approve.

Sigh.

 

[Corpseman]

I would have to go thru the whole rigamarole again. And I was titrating, so the patient was supposed to take one half to two of the twenty fives qhs.
This is why we get annoyed. Such a waste of time and the patient needs the meds asap.
I called one company for a PA, and they said it would take seven to fourteen days to approve.

Sigh.

And yet you blame the pharmacists why?

 

[Jibby321]

I would have to go thru the whole rigamarole again. And I was titrating, so the patient was supposed to take one half to two of the twenty fives qhs.
This is why we get annoyed. Such a waste of time and the patient needs the meds asap.
I called one company for a PA, and they said it would take seven to fourteen days to approve.

Sigh.

Got ya. Yea. It's a pain in the ass.

 

[504poboy]

I would have to go thru the whole rigamarole again. And I was titrating, so the patient was supposed to take one half to two of the twenty fives qhs.
This is why we get annoyed. Such a waste of time and the patient needs the meds asap.
I called one company for a PA, and they said it would take seven to fourteen days to approve.

Sigh.

Whoa hold on! I got another solution for you. This is per CMS guidelines and generally commercial insurance plans.

The insurance needs information from you regarding the exception. The information needed for a supporting statement depends on the type of exception that is being requested. There are 5 types of exceptions which are as follows:
1. Formulary Exceptions - used to request coverage for a non-formulary drug
2. Quantity Exceptions - used to request coverage for a quantity of drug in excess of that allowed by the plan
3. Step Therapy Exception - used to request a waiver of utilization management rules that would restrict access to a formulary drug unless the member first tries and fails one or more lower cost drugs
4. Tiering Exceptions - used to request a lower co-pay or cost share
5. Prior Authorization Exceptions - used to request a waiver of the plan's prior authorization criteria
a. May also be referred to as a medical necessity exception or coverage rule exception.

Your problem is a Quantity Exception. You need to explain in full detail for your supporting statement on why the patient needs to get 2 quietapine 25mg instead of the 50mg tablet. You can add that he is mentally stable on this particular regimen and compared to another regimen. Make sure you're extra nice on the phone when you talk to the person on the other side. Nowadays, the prior authorization is done by a technician. Alot of them do not know the clinical consequences of why certain meds are needed. This is how I explain to some doctors. Imagine you're trying to tell a story. You want to paint that person a picture. Paint the person a pretty picture (story). This story needs to be documented well because CMS is the person reading these stories when they do random audits on the insurance companies. The insurance companies get audited by CMS hard. Sometimes these paintings can be a half a page to a full page. Paint a pretty story!!

 

[PikminOC]

Whoa hold on! I got another solution for you. This is per CMS guidelines and generally commercial insurance plans.

The insurance needs information from you regarding the exception. The information needed for a supporting statement depends on the type of exception that is being requested. There are 5 types of exceptions which are as follows:
1. Formulary Exceptions - used to request coverage for a non-formulary drug
2. Quantity Exceptions - used to request coverage for a quantity of drug in excess of that allowed by the plan
3. Step Therapy Exception - used to request a waiver of utilization management rules that would restrict access to a formulary drug unless the member first tries and fails one or more lower cost drugs
4. Tiering Exceptions - used to request a lower co-pay or cost share
5. Prior Authorization Exceptions - used to request a waiver of the plan's prior authorization criteria
a. May also be referred to as a medical necessity exception or coverage rule exception.

Your problem is a Quantity Exception. You need to explain in full detail for your supporting statement on why the patient needs to get 2 quietapine 25mg instead of the 50mg tablet. You can add that he is mentally stable on this particular regimen and compared to another regimen. Make sure you're extra nice on the phone when you talk to the person on the other side. Nowadays, the prior authorization is done by a technician. Alot of them do not know the clinical consequences of why certain meds are needed. This is how I explain to some doctors. Imagine you're trying to tell a story. You want to paint that person a picture. Paint the person a pretty picture (story). This story needs to be documented well because CMS is the person reading these stories when they do random audits on the insurance companies. The insurance companies get audited by CMS hard. Sometimes these paintings can be a half a page to a full page. Paint a pretty story!!

I'm not doing it again. I don't even know why i tried that one. Waste of time.

 

[PikminOC]

To that point, a pharmacist made the decision and I got a form letter.
My other patient wants an exception for vivitrol, and I told her I wont try. I did give her a coupon for it. All these things are such a waste of time.

 

[Jibby321]

#thanksobama

 

[Corpseman]

To that point, a pharmacist made the decision and I got a form letter.
My other patient wants an exception for vivitrol, and I told her I wont try. I did give her a coupon for it. All these things are such a waste of time.

Taking the time out to help your patients is a waste of time?

 

[504poboy]

These exceptions are either Approved or Denied. Approved exceptions are good for 1 to 2 years if it is a private commercial insurance. If it is a Medicare plan, it is good for UP to 10 years depending on the plan and the type of exception. Now if the patient switches to a different medicare plan. You have to do the entire process all over again. You can always request for a expedited decision by writing the word URGENT on the top of the page or anywhere on the page or writing it out as a sentence to the effect of "This request requires expedited review".

 

[504poboy]

#thanksobama

Obama has nothing to do with these rules. These are rules and regulations made by CMS that insurance needs to follow. IF you want to thank Obama, google the "cadillac tax aca" ACA = Affordable Care Act. IF you thought it was bad now, wait until the Cadillac tax provision goes into effect.

 

[504poboy]

To that point, a pharmacist made the decision and I got a form letter.
My other patient wants an exception for vivitrol, and I told her I wont try. I did give her a coupon for it. All these things are such a waste of time.

Understand how your mind learns.

The pyschological field of neurolinguistic programming (NLP) offers a useful four-step model of how the mind learns. It can serve as yardstick to measure your progress.

1. Unconscious incompetence: You're doing something wrong, and you don't even know you're doing it wrong.
2. Conscious incompetence: You're doing something wrong, and you're aware that you're doing it wrong, but you haven't yet fixed the problem.
3. Conscious competence: You've learned the right way to do it, and you're doing it correctly with focused attention.
4. Unconscious competence: You no longer have to think about something or work on learning it - you automatically do it correctly. This is when you become a so-called natural.

Can you guess where you are in regards to learning of the prior authorization process?

 

[Jibby321]

Obama has nothing to do with these rules. These are rules and regulations made by CMS that insurance needs to follow. IF you want to thank Obama, google the "cadillac tax aca" ACA = Affordable Care Act. IF you thought it was bad now, wait until the Cadillac tax provision goes into effect.

The joke is clearly over your head. Good try though.

 

[PikminOC]

Understand how your mind learns.

The pyschological field of neurolinguistic programming (NLP) offers a useful four-step model of how the mind learns. It can serve as yardstick to measure your progress.

1. Unconscious incompetence: You're doing something wrong, and you don't even know you're doing it wrong.
2. Conscious incompetence: You're doing something wrong, and you're aware that you're doing it wrong, but you haven't yet fixed the problem.
3. Conscious competence: You've learned the right way to do it, and you're doing it correctly with focused attention.
4. Unconscious competence: You no longer have to think about something or work on learning it - you automatically do it correctly. This is when you become a so-called natural.

Can you guess where you are in regards to learning of the prior authorization process?

Wow.
I'm not doing anything wrong. I'm prescribing the meds at the quantities I think will help my patients. The PA process is more unneeded hoops. And you know it.

 

[PikminOC]

Taking the time out to help your patients is a waste of time?

Having to do these second steps in unnecessary. It is between the insurance and patient. Not me. I evaluated them and gave a course of treatment.

 

[BenJammin]

Step 1: hire office staff.

 

[Corpseman]

Having to do these second steps in unnecessary. It is between the insurance and patient. Not me. I evaluated them and gave a course of treatment.

Probably not the most cost effective for the patient, so yes it is still between you and the patient.

 

[gwarm01]

Taking the time out to help your patients is a waste of time?

Jumping through hoops to help insurance companies make a profit while delaying appropriate therapy for our patients is a waste of time. The whole process is needlessly difficult.

 

[PikminOC]

Jumping through hoops to help insurance companies make a profit while delaying appropriate therapy for our patients is a waste of time. The whole process is needlessly difficult.

Thank you for understanding. Yes it is difficult on us, you, and the patient!

 

[Dred Pirate]

Jumping through hoops to help insurance companies make a profit while delaying appropriate therapy for our patients is a waste of time. The whole process is needlessly difficult.

Having to do these second steps in unnecessary. It is between the insurance and patient. Not me. I evaluated them and gave a course of treatment.

Yes - we all agree we hate the PA process .

I haven't worked retail in years, and this is one of the reasons. But we all have to agree there is a rhyme and reason to many of the PA's (I think back to when prilosec was generic, there was no reason to try it before trying nexium at 5 times the cost). Many of the PA's are frustrating for all of us, but it does save money. Which means (in an ideal world) lower premiums, higher reimbursements (or at least less cuts to reimbursements for MD's and Rph's)

The problem with your thought process ( @GroverPsychMD ) is that , yes, it is still between YOU and the Patient. You suggested treatment, but if the insurance company isn't going to pay for it, you might as well did nothing. You can hire cheap office staff to do this paperwork. (most of it). I work in an ED and see these patients all the time, "I couldn't afford my meds and now I hear voices telling me to kill myself or others". By not doing this process you are putting your patients and potentially other innocent people at risk. That is on you and no matter how you try to spin it, ultimately if you were the pysch MD that treated one of these mass killers and it comes back that the reason they weren't on their meds is because the doctor didn't want to fill out the paperwork - can you imagine what a field day the media would have with that?

 

[PikminOC]

Patient's say they cant afford $4 meds. At some point they have to take responsibility. Maybe I should do directly observed therapy as well?

 

[BenJammin]

Patient's say they cant afford $4 meds. At some point they have to take responsibility. Maybe I should do directly observed therapy as well?

Tell them to stop breaking the rules by not getting health insurance. Tax penalty is more expensive than most cheap ACA plans.

 

[Dred Pirate]

Patient's say they cant afford $4 meds. At some point they have to take responsibility. Maybe I should do directly observed therapy as well?

$4 med is a lot different than most of the atypical anti psychs out there - most are several hundred - there are not PA's on $4 meds

those are two different conversations (and I agree with pt's taking responsibility, but when you refuse to fill out a PA form there is nothing they can do - other than find a new doc, which as a Rph I would recommend they do)

 

[PikminOC]

You can tell them whatever you want. That's fine with me.
I'm just telling you how I feel about this process.

 

[JustAnotherRph]

It is one thing to be irritated and angry at the process and another of treating pharmacists as the cause to your frustration. It isn't pharmacists making decisions on where to put the PA or how many hoops you have to jump through to get it. If you want to complain about the process, complain to the government, but do not take it out on pharmacists.

Keep in mind that it isn't always clinical people making decisions for formularies in their health plans. Some decisions are based strictly on rebate dollars and not clinical sense. Medicare and Medicaid are great examples of those without a clinical background making clinical decisions solely based on cost.

 

[JustAnotherRph]

To that point, a pharmacist made the decision and I got a form letter.
My other patient wants an exception for vivitrol, and I told her I wont try. I did give her a coupon for it. All these things are such a waste of time.

In most states, pharmacists cannot deny a prior authorization, only a medical doctor can. However, if a pharmacist denied it, it was on direction from a medical doctor on the rules that a pharmacist must follow. In this case, you can blame your fellow colleagues on that.

 

[PikminOC]

In most states, pharmacists cannot deny a prior authorization, only a medical doctor can. However, if a pharmacist denied it, it was on direction from a medical doctor on the rules that a pharmacist must follow. In this case, you can blame your fellow colleagues on that.

I'm only blaming the insurance companies.

 

[SClENCE]

Honestly just tell the patient they can pay for it or change the med. Your job isn't to save them money.

It always amazes me how people flip over over something that costs $50. Yeah the drug company just invested a billion dollars to get this on the market, do you really think that they are going to hand it out for free? Not to mention that you insurance (most likely the tax payers) is already covering 95% of it.