Retail Pharmacy: Explaining Prior Authorizations to Patients

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RAMPHARMD

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I work in a rural area of the south where pharmacy frequenters come in only 3 flavors: old, stupid, or a combination of both. The concept of a prior authorization to the majority of these people is not one that is easily understood.

I'm trying to determine a way to quickly and effectively communicate to patients that their third-party payer has temporarily (or permanently) refused to cover their pricey prescription drug(s) and would like suggestions from the SDN community.

How do you break the news to the patient?


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"allright lemme run this through your insurance....(pops up PA)....looks like this isn't covered, your insurance is requiring your doctor to contact them. i'll go ahead and contact your doctor about the paperwork or if they want to change you to something else that's covered....

do you know how fast your doctor's office is? (blah blah they're slow as hell)....yeah, well you might want to call them and let them know you need it, i'll go ahead and fax them."

something like that, it's all about deflection. notice how i guide the conversation to make it look like the insurance co. is the bad guy and that i can't do anything/am doing everything i can. Also notice how i bring up how slow their MD's office is so they'll get an idea how long it'll take for them to file.


pt: "how long does this usually take?"
me: "well...once your doctor gets the paperwork into your insurance company, it's usually 3 business days on their end...soooo depending on how fast/slow your doctor's office is, about a week? check back with us then"

oh, date stamp your faxes to cover your ass
 
Yeah, I kinda say the same as above.

"Okay, so your insurance is requiring some paperwork from your doctor before they will cover this medication. I'll go ahead and fax the doctor to let him know, but they usually take awhile to follow-up, so I suggest you call your doctor and let him know that we've faxed him with more information on how to contact your plan."

...aaand I say it all really fast so they have no time to butt in with comments. lol may sound mean, but i worked in miami and those customers are EVIL! :laugh:
 
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Your medication requires a prior authorization so go and call your doctor to have him contact the insurance and stop relying on me to babysit your lazy butt :D:D

I wish i could say that but maybe my last day as a pharmacist. Make it short and simple like ur med. req. prior authorization which means ur doc has to contact the insurance to authorize it or change the medication (end of story). Patient might be lazy and say don't u guys contact them and do ALL THE WORK. U should respond and say i faxed them but u can call ur doc and check to see they get it and explain it to them.
 
I say, "You're insurance company doesn't want to pay for this medication because it's expensive and they want to make sure your doctor thinks you really really really need this so they're going to make him fill out some paper work before they have to pay for it."

Or I say, "El seguro no quiere pagar para la medicina porque es muy caro. Ellos quiere hablar con su doctor" with a lot of hand gestures.
 
something like that, it's all about deflection. notice how i guide the conversation to make it look like the insurance co. is the bad guy and that i can't do anything/am doing everything i can. Also notice how i bring up how slow their MD's office is so they'll get an idea how long it'll take for them to file.

Exactly. I talk slowly and explain that continually calling us isn't going to make your prior auth go away any faster.
 
"Okay, looks like your insurance doesn't want to cover this drug unless they talk to your doctor, which is called a prior authorization. Basically, all insurance companies have a list of preferred drugs and the drug your physician prescribed wasn't on the list, hence it is not covered. You can either pay cash price for it, or you can contact your doctor to contact the insurance company."

Basically, I print out the screen with the phone number the doctor has to call and give that to the patient. We're not initiating prior authorizations anymore, simply taking up too much space in the pharmacy and too much of a hassle. We give the scripts back to the patients, and let them hound the physician to call the insurance company.

However, I have had one incident when the insurance company said that they could do the prior authorization with me instead of the physician, which was super cool.

Situation
Patient needed to get Nexium. She recently changed insurance plans, and her previous insurance company covered Nexium. However, her new insurance company requires that she uses omeprazole first.

So basically, the person asked me if she had used omeprazole in the past before using Nexium, checked the profile and confirmed that she did. Prior authorization went through and is good for a year.
 
I would actually avoid using the words "prior authorization" because...well...people are just dumb. You'll end up getting into an argument about semantics and the words "prior" and "authorization"

I would avoid even trying to explain what a PA is. I only bring this up with pt's who know what's going on (you'll have a few). Sometimes their stuff requires a PA annually and will probably know that going in (pt: "oh yeah it's been a year ::sigh:: okay i'll come back next week).

in short.. "not covered...your insurance needs a doctor's approval/letter before they'll cover it."


and yes i'm like semi-pro in pharmacy spanish too...haha. Quince minutos en la otra ventana!
 
i say......

your insurance won't cover this untill you doctor gets in touch with them. call your MD and tell them to call the insurance for a prior auth.

then you have to explain to them that they're not the only ones this has happened to and that the doctor will know what they're talking about lol

i want to just say pay the cash price or call your doctor good bye and walk away!
 
i dont think ppl are 'stupid'. they just probably dont know the lingo of pharmacy just like we wouldnt know the lingo of some other uncommon profession. its our job as the pharmacy staff to explain it to them.

i say..."your prescription needs a prior authorization. a PA is when your ins company wants justification from your doctor for why he/she prescribed you the medication. what we do is notify the md via fax and then the md should get a hold of the ins. the ins will then approve or deny it."

depending on what they say after that, i give them their options on what they can do.

remember, PAs arent just necessarily due to meds being expensive.
 
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Usually I try to ease the blame from us pharmacy staff by saying stuff like:

"Because YOUR doctor prescribed this drug, your insurance will not cover it unless HE/SHE talks to them. We have nothing to do with this."

"YOUR insurance does not want to cover this drug because they think YOUR doctor could have prescribed you something else for this condition"
 
Usually I try to ease the blame from us pharmacy staff by saying stuff like:

"Because YOUR doctor prescribed this drug, your insurance will not cover it unless HE/SHE talks to them. We have nothing to do with this."

"YOUR insurance does not want to cover this drug because they think YOUR doctor could have prescribed you something else for this condition"

yeah...sometimes i throw in the "yeahh....i know, it happened to me not too long ago, it's these insurance companies..." when it looks like they're about to pop.

PBM's are up there with big oil, banks, and "the government" in that it's easy to turn it into an abstract, monolithic idea to which we have no control over. Makes my life easier.

I used to do enrollments when I was an undergrad and I'd get irate parents demanding to see their child's grades. I'd basically read them the riot act (in this case, FERPA) and they'd shut up quick. Nothing stops a conversation like "federal privacy laws prohibit...."
 
i usually just tell the patients that their insurance does not cover the medication unless the doctor get the approval through the insurance. Then i let them know i sent a fax to the doctor to contact the insurance.

if they ask how long it will take? I tell them that i dont know what the doctor is going to do. Not sure if he's going to get the approval or change the medication. Then i tell them just contact their doctor to speed things up...

the more you deal with this issue, the easier it is to explain everything...
 
I've never worked in retail....Is it fairly possible to run an alternative through the insurance company to determine what's actually covered and give this info to the doctor (ie, Nexium is not covered but Omeprazole is), instead of the MD sending a new rx based on trial and error, until the rx sent is what's actually covered??? Because seriously, the pharmacy's guess on what/what's not covered is as good as the doctor's (Unless your doctor is ahead of the pack in e-prescribing and has invested in RxHub)! Until somebody comes up with a universal source of drug formularies, the doctor's office, pharmacy, insurance companies are gonna be playing the blaming game with the pt stuck in the middle!
 
I've never worked in retail....Is it fairly possible to run an alternative through the insurance company to determine what's actually covered and give this info to the doctor (ie, Nexium is not covered but Omeprazole is), instead of the MD sending a new rx based on trial and error, until the rx sent is what's actually covered??? Because seriously, the pharmacy's guess on what/what's not covered is as good as the doctor's (Unless your doctor is ahead of the pack in e-prescribing and has invested in RxHub)! Until somebody comes up with a universal source of drug formularies, the doctor's office, pharmacy, insurance companies are gonna be playing the blaming game with the pt stuck in the middle!

Sounds like a good idea, but more often than not the pharmacists are way too busy to do this.
 
I've never worked in retail....Is it fairly possible to run an alternative through the insurance company to determine what's actually covered and give this info to the doctor (ie, Nexium is not covered but Omeprazole is), instead of the MD sending a new rx based on trial and error, until the rx sent is what's actually covered??? Because seriously, the pharmacy's guess on what/what's not covered is as good as the doctor's (Unless your doctor is ahead of the pack in e-prescribing and has invested in RxHub)! Until somebody comes up with a universal source of drug formularies, the doctor's office, pharmacy, insurance companies are gonna be playing the blaming game with the pt stuck in the middle!

I have the Blue Shield, CA ADAP, Medi-Cal, PHP/PHPMM, and Unity formularies on my PDA (via epocrates) and usually after working a while you just know what's covered and what isn't (no Lunesta, yes zolpidem; no Nexium, yes omeprazole; no ). If it's a nice pt/repeat customer and it's not busy, I'll quickly type in random scripts in the same class to see what's covered.

Good PBM's actually give you what's covered in the secondary reject field (ie step therapy, generic only, etc...), but most don't. When I submit PA's I'll usually put "OR change to...." on the fax.

Here's a screenshot of my PDA for Ciprodex:
IMG_0475.png
 
This is actually probably the better example:

IMG_0476.png


ST indicates step therapy, PA for PA, N for nonform, Y for covered
 
PA/TAR/PER etc...I tell patients the medicine is not covered right away and needs paper work to get it covered. We send your doctor a fax and the doctor has to call the insurance company. And then the insurance tells us, the pharmacy, if the medicine is approved or not. If you want the medicine now, you can pay for it and get reimbursed only if the insurance covers the medicine later. If you don't want to pay for it now, the paper work process takes 2 to 3 days. Here is our business card, call us later to find out if it was covered. Calling before hand will save you a trip. thank you. good bye. NEXT!!

When a medication is not covered, (depending on what insurance patient has), the electronic response will usually tell why it is not covered. Example: Prior Authorization required or GENERIC REQUIRED, or INVALID BIRTHDAY/SEX, etc.

Like Confeti said, you can run what we call the "fake script" to see if the insurance covers an alternative medication. If the alternative is covered, the pharmacist can speak to the prescriber and possibly, have it changed to what's covered. If the prescriber says no then the prescriber is made aware of the PA process. (I can't imagine retail settings having all the time to make these MD calls, but we do)

Depending on the insurance company, sometimes you can go to their website and check what drugs are covered on their formulary list. This usually takes forever and to my knowledge, is seldom done. Thus, most pharmacy staff do it all by trial and error and they're really good at it. You have to be..
 
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(I can't imagine retail settings having all the time to make these MD calls, but we do)

Fax is your friend! We had premade forms and just stuck the now no-good Rx label, a few words, and stamp the date...and hit send. Most offices now no longer accept phone calls for anything (makes sense, most MD's are swamped and can't spare the minute anymore). Rather than be on hold for 5 mins, I'll take 2 and fill out the form/fax it off. If it's after hours/weekends, I just bundle it together in a "to do" file I'll finish at the end of my shift if there's a line.

Usually ER's are good about formulary, BUT now and again we'll get one (ciprodex --> cortisporin was one). I hate calling the ER, I feel so bad for having to talk to the attending to get a change. I've learned how to sound sorry and get what I need to say out in as few words as possible. I'll throw in the word "cal optima/medi-Cal" and they'll usually understand.
 
Fax is your friend! We had premade forms and just stuck the now no-good Rx label, a few words, and stamp the date...and hit send. Most offices now no longer accept phone calls for anything (makes sense, most MD's are swamped and can't spare the minute anymore). Rather than be on hold for 5 mins, I'll take 2 and fill out the form/fax it off. If it's after hours/weekends, I just bundle it together in a "to do" file I'll finish at the end of my shift if there's a line.

Usually ER's are good about formulary, BUT now and again we'll get one (ciprodex --> cortisporin was one). I hate calling the ER, I feel so bad for having to talk to the attending to get a change. I've learned how to sound sorry and get what I need to say out in as few words as possible. I'll throw in the word "cal optima/medi-Cal" and they'll usually understand.


You're right. Fax is the best way to go when everyone is busy. I guess I've been a little spoiled at the hospital and our MDs return our calls and pages fairly quickly; most of the time.

During peak and after hours, we also fax a lot. Our ER dept. prefers faxes since they get to see exactly what's wrong with the script. Most of the time, residents write the prescriptions and the attending sign it off. I was always told to speak to the resident doctors first since the attending MDs might get pissed off at us...
 
Fax is only second best!!! Let's start thinking electronic, people! I hate faxes... and phone calls! Believe it or not, your large chain pharmacy has the ability to send PA requests, refill requests, other such requests electronically (That includes Walgreens, CVS, Rite-aid....). Now whether the doctor's office receives that request directly into the pt's EMR or as a fax (lame) depends on how much the doctor's office/your physician group has adapted to the wonderful world of electronic medical records. But if in fact your doctor is ahead of the game, your large chain pharmacy is even one-step further and should be able to send these messages electronically!
 
Fax is only second best!!! Let's start thinking electronic, people! I hate faxes... and phone calls! Believe it or not, your large chain pharmacy has the ability to send PA requests, refill requests, other such requests electronically (That includes Walgreens, CVS, Rite-aid....). Now whether the doctor's office receives that request directly into the pt's EMR or as a fax (lame) depends on how much the doctor's office/your physician group has adapted to the wonderful world of electronic medical records. But if in fact your doctor is ahead of the game, your large chain pharmacy is even one-step further and should be able to send these messages electronically!

Well....when we send electronic requests, it pops out as a fax on their end. When they send escripts to us...it a) pops out as a fax on our fax machine or b) we have to print it anyway and scan it.

What is this electronic stuff you speak of, future woman? hahaha
 
Fax is only second best!!! Let's start thinking electronic, people! I hate faxes... and phone calls! Believe it or not, your large chain pharmacy has the ability to send PA requests, refill requests, other such requests electronically (That includes Walgreens, CVS, Rite-aid....). Now whether the doctor's office receives that request directly into the pt's EMR or as a fax (lame) depends on how much the doctor's office/your physician group has adapted to the wonderful world of electronic medical records. But if in fact your doctor is ahead of the game, your large chain pharmacy is even one-step further and should be able to send these messages electronically!

I think what ismellLikflower means by electronic orders are new prescriptions or refills that are submitted via computer to computer. The MD types up the order and submits it on his or her computer and the pharmacy's computer receives it and the printer rolls out the new orders / refills. I've seen these kind of orders but they are very rare where I work.

Personally, I prefer the good old prescriber signatures on the physical prescriptions or faxes from the doctor's offices. I'm okay with electronic medical records as long as we also back it up with physical copies. yes, electronic orders are fast and contributes to the increase in retail pharmacy volumes. But if we don't have a physical copy, a couple computer hackers can break into the medical records data bases and steal everything. This can potentially lead to identity theft and the violation of privacy. I sound really paranoid, but this is entirely possible.
 
I hate the fax. There's no immediate response. We're lucky to get faxbacks within 3 days (refill requests, changes, etc). Meanwhile we're getting pestered every day (or more frequently with the really annoying patients) on why we haven't processed it because they're MD is ALWAYS really prompt, and there's no way they couldn't have faxed it back to us by now.:mad:
 
This can potentially lead to identity theft and the violation of privacy. I sound really paranoid, but this is entirely possible.


Like that thing in Virginia? That's a different issue. e-records are better in that it's easier to steal hard copy records without a trace vs. there being a digital trail.

At UPenn, anytime you access certain restricted pt records, it requires you to drag an image of a hammer onto glass to "break the seal" and your ID recorded...whereas with a paper chart, I can just grab it off the shelf, read it, and slip it back.
 
I think what ismellLikflower means by electronic orders are new prescriptions or refills that are submitted via computer to computer. The MD types up the order and submits it on his or her computer and the pharmacy's computer receives it and the printer rolls out the new orders / refills. I've seen these kind of orders but they are very rare where I work.

Personally, I prefer the good old prescriber signatures on the physical prescriptions or faxes from the doctor's offices. I'm okay with electronic medical records as long as we also back it up with physical copies. yes, electronic orders are fast and contributes to the increase in retail pharmacy volumes. But if we don't have a physical copy, a couple computer hackers can break into the medical records data bases and steal everything. This can potentially lead to identity theft and the violation of privacy. I sound really paranoid, but this is entirely possible.


The chance of electronic medical records being hacked is virtually nothing compared to the chances of having medication errors due to incorrect transcription of these "good old" hardcopy rx's. Sure, most would say catching these mistakes is what pharmacists are for, but honestly, as a future pharmacist, I would like to think that this is not the entirety of my job description. In adapting this "future" technology, pharmacists could focus less on mundane tasks (e.g. checking the refill box actually says 3, not 2) and give more attention to details that require critical thinking.

The reason why you don't see a prevalence in e-prescribing is because the incentive for MD's to adapt the technology is like pennies. Moreover, your large chain pharmacy prefers not to use it because it's actually costing them more to do these transactions "computer to computer."
 
I think what ismellLikflower means by electronic orders are new prescriptions or refills that are submitted via computer to computer. The MD types up the order and submits it on his or her computer and the pharmacy's computer receives it and the printer rolls out the new orders / refills. I've seen these kind of orders but they are very rare where I work.




The chance of electronic medical records being hacked is virtually nothing compared to the chances of having medication errors due to incorrect transcription of these "good old" hardcopy rx's. Sure, most would say catching these mistakes is what pharmacists are for, but honestly, as a future pharmacist, I would like to think that this is not the entirety of my job description. In adapting this "future" technology, pharmacists could focus less on mundane tasks (e.g. checking the refill box actually says 3, not 2) and give more attention to details that require critical thinking.

The reason why you don't see a prevalence in e-prescribing is because the incentive for MD's to adapt the technology is like pennies. Moreover, your large chain pharmacy prefers not to use it because it's actually costing them more to do these transactions "computer to computer."



oh e-prescriptions....I love getting the ones for 36 tablets of azithromycin, or the 115,000L orders of prometh/codeine :smuggrin:

But yeah, hopefully within 10 years we'll advance enough that Rx transmission can be a 2 way process. For example, MD sends a script for test strips, RPh requests dx code, MD can append to it. It's like a script with an AIM transcript. Or MD sends a script for an odd dose of something, RPh asks for justification/clarification (ie ped pt), MD responds.
 
I posted this thread to Facebook and asked that it be shared. I'm sure a lot of people would like to see what pharmacists think of them. It's good to know we have a bunch of immature, smart a** children behind the counters handling our medications.
 
I posted this thread to Facebook and asked that it be shared. I'm sure a lot of people would like to see what pharmacists think of them. It's good to know we have a bunch of immature, smart a** children behind the counters handling our medications.

Congrats. :thumbup:

3 years later, I'll agree that people are stupid.
 
I posted this thread to Facebook and asked that it be shared. I'm sure a lot of people would like to see what pharmacists think of them. It's good to know we have a bunch of immature, smart a** children behind the counters handling our medications.

Would you rather we lie? :poke:
 
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