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Prescription fix: DIY?

September 29th, 2004 · 1 Comment

I’m starting to believe medication is a miracle – that is if one can afford to fill a prescription. My doctor gave me some trial samples and I called to get a prescription for more. However, my pharmacy notified me that our insurance would not cover this particular drug. So I had to go back to square 1.

I asked my health insurance company how to know which medicines are covered by the plan. The employee told me that the physician’s staff could look on the insurance company’s website and find the formulary there.

Then I called the physician’s office and requested an alternate prescription. In the past we as a family have seen doctors who looked at our chart, saw our insurance and prescribed according to what they knew would be covered by that plan. I was surprised that I had been given a drug which wasn’t covered. Our insurance is not a podunk plan: it is one of the larger companies in the state. I realized that based on past experiences, I expect my doctor to consider my coverage. Or at least help accommodate me and my needs.

Instead, the nurse at the doctor’s office told me that I needed to find out which drugs were covered. Since I don’t have much medical knowledge or a degree in pharmacy, I didn’t know how I would be able to know my options.

When I repeated the insurance company’s instructions that the physician’s staff could use the website, the nurse refused. She said that she didn’t have the 10 – 15 minutes to learn how to use the site. It sounded like she had never used the website. I was surprised, especially since my insurance provider is one of the larger ones. I was surprised too that I was on my own.

The insurance company told me that the doctor should use the web site to figure out the formulary. But the doctor’s staff told me to find it out for myself.

After a brief tug of war on the phone when I, frustrated, nearly insisted on looking it up myself on the Web, the nurse decided to employ my pharmacy since they would be able to determine the pricing and coverage quickly for a couple different options.

In the meantime, I went to my insurance company’s site. Within two or three clicks, I found the list of drugs allowed. It took ten seconds intead of ten minutes.

I understand that my doctor’s staff have a lot of work to do. But I wish that they knew how to use my insurance company’s web site. I would expect that this would be common knowledge. Considering the amount of money we pay each year into insurance and medical bills, I would expect better communication and service than a DIY (do-it-yourself) attitude transmitted to the patient.

I also wish that I wouldn’t end up in the middle, stranded between my insurance and my physician. It was an uncomfortable place to be, both consumer and conduit.

I know now though that the next time it happens, I’ll be sitting at my laptop, surfing through the formulary to find a prescription to request…

Tags: health

1 response so far ↓

  • 1 enoch choi // Sep 29, 2004 at 1:35 am

    that’s awful, but a common experience. Our billing system passes the insurance information to our EMR (electronic medical record) which i use in the patient’s exam room to look up medications, and the EMR tells me if it’s on formulary or not. At least that’s how it’s supposed to work. It’s not bug-free, but it works most of the time. It’s kind of ridiculous for the nurse to tell you to go find out what’s covered since you wouldn’t know an appropriate alternate RX. It’s common for the nurse to tell a patient to work with the pharmacist, though. They know the appropriate substitutes, and know your insurance plan. What a pain!