Why is Filling this Prescription so confusing?
June 4, 2020 7:58 PM   Subscribe

Hi, AskMe. :) I have a prescription for medicine for non-24 Sleep Disorder, which has dogged me for years due to my blindness. Filling it has been difficult. I'm just curious as to why>

A couple things have bugged me about this prescription. I was told that I needed to get it pre-authorized, which I have asked the doctor's office to help me do.

I then got a call from my local pharmacy, saying that they can't fill the prescription because it isn't available for them to purchase? I called the drug company and was told that the medication is only available from a couple different pharmacies, with names I hadn't ever heard of. it was up to my insurance to tell me which one I needed to contact. I was on hold for over an hour before I got a name from the insurer.

After all that, I was told to contact the old pharmacy to get them to fax (?) the prescription info over. I did so and was told that no, they actually can't do that, it's the doctor's job. So I called him and finally hope I've solved this situation, at least until the pre-authorization comes back.

i'd just like to understand what was happening here? If the med can only be distributed from a couple places, why isn't the doctor made aware of that? What's with the fax machines? I'm told they needed to fax my pre-authorization request too, which baffles me. Any medically-inclined Mefites care to shed light on this, I'd love to hear the story :)
posted by Alensin to Health & Fitness (8 answers total)
The deal with fax machines is...the retail medical industry is still in the Dark Ages. Lots of faxes, lots of phone calls. Until COVID, for one of my meds, I had to get a separate prescription every month and hand-deliver it to the pharmacy to fill.

If most people just go to CVS or Walgreens, then the doctor may not even be aware that the script requires special care. My allergy doc prescribed me something that wasn't on my insurance formulary - two drug nasal-spray - but the individual constituents were. On my follow up visit, he asked why I wasn't taking as prescribed and was shocked to learn of the formulary issues and substitution. Luckily, my pharmacist is awesome...
posted by notsnot at 8:11 PM on June 4, 2020 [1 favorite]

It sounds like the medication is not readily available and is quite expensive. I assume the pre-approval is because of the expense. The fax is for legal reasons. Fax transmission is considered secure for privacy and legal signature purposes. I am not a lawyer, but that is my recent personal experience. As for the limited pharmacies that carry it, I am also not a pharmacist but I am friends with one. What he carries and can get is dependent on wholesalers. If this medication is as expensive as it sounds, not many wholesalers are going to inventory it. If this is now going to be a regular prescription, the local pharmacy will work with the manufacturer, the insurance company and the wholesalers to ensure supply.
posted by AugustWest at 9:00 PM on June 4, 2020 [2 favorites]

I've learned that (some) doctors just honestly don't often know several things about the drugs they prescribe. Of course they know what to prescribe for certain conditions. But they don't generally know how much the drugs cost, the formulations, or if pharmacies carry certain drugs. Honestly, though, I don't feel like that's information they necessarily need to know. That's what awesome pharmacists are for! Unfortunately, you got caught up in the middle this time.
posted by cooker girl at 9:31 PM on June 4, 2020 [6 favorites]

Best answer: You might ask the doctor to see if there is a mail order pharmacy that is "preferred" by the insurer. They do this sometimes to funnel unusual, expensive medications to one pharmacy so they are sure the distribution is smooth and the designated pharmacy contacts every patient before arranging mail order delivery. This would be a question for your insurer, and will involve your doctor forwarding the prescription to the mail order pharmacy. In this case, since a local pharmacy currently has the script, they will need to actively electronically "cancel" it. All this to insure that the script is filled only once.

You might be able to shorten this by speaking with an insurance rep, or more specifically the PBM or pharmacy benefits manager (CVS Homecare is one). There is also a flotilla of expensive new drug pharmaceutical personnel who work to make sure that filling the prescriptions works smoothly, often called patient assistance programs. It's not always about covering expensive, unaffordable co-pays, though they can help with that. They will hold your hand and figure out what all the hold-ups are. THEY contact the doctor to make any alterations in the prescription that is required (like from 30 days to 90 days, or contacting pharmacies to reverse the script and direct it to the correct pharmacy.) Their job is to make sure that whatever hoops your insurer has in place, they jump over them. They will be go-betweens to figure out just what the hold-ups are and can be the absolute key to smoothing all this out. These sorts of advocacy groups - paid for by the pharmaceutical company - will be noted in the advertising. "If you can't afford your medicine or are uninsured, we can help" - that sort of thing. Call that number and explain your situation.

Is there is a nurse at the doctor's office who will advocate for you? As a nurse I was a regular go-between for patients filling expensive medications and insurers, who want to make sure the expensive medications are properly dispensed and not languishing, potentially stored incorrectly, in a typical neighborhood pharmacy. We scrambled to move prescriptions if required when insurers changed, or formularies changed. We scrounged up doses to bridge insurance gaps, long holidays when pharmacies closed (Christmas thru New Year, every damn year) and when housefires or floods wiped out patient medications. Nurses kick butt, actually, on behalf of patients. The trick is simply to find out what the insurer prefers and try to get all the parties - doctor, nurse, pharmacist - on the same page.
posted by citygirl at 10:36 PM on June 4, 2020 [7 favorites]

It sounds like your medication is only available via specialty pharmacies. As mentioned by citygirl above, health insurance companies or their contracted pharmacy benefit manager companies only set up relationships with their preferred specialty pharmacies (usually only 1-2 are “in plan”). If you want to get angrier about healthcare in the US, read about PBMs and their scammy pharmacy relationships - Pharma Bros are the worst.

My son takes a medication that the pharma company restricts distribution on - it is only available via 3 or 4 specialty pharmacies in the US. All of them except one are mail order (and the non-mail order option only exists because I battled the Pharma company myself and got the local hospital pharmacy to carry it). For a couple years none of those pharmacies were “in plan” according to my insurance, so we had to apply for an exemption to go outside the plan to fill that prescription. This year we had to switch to a new specialty pharmacy due to a contract change with the PBM (burn in hell, Walgreens Alliance Prime RX), which involved more paperwork and bullshit.

I did zero faxing myself - my son’s nurse practitioner and her clinic’s pharmacy coordinator jumped through the hoops on our behalf. I’m sorry there’s no one on your medical team stepping up for you here - please reach out to them for help! Be careful about interacting with any of the drug manufacturer patient assistance programs, especially if they want you to sign any HIPAA or release of information paperwork. The patient assistance program for my son’s medication is a department of the pharma company, and signing their HIPAA form meant giving permission to share literally all of his medical records with them. There’s no way I was giving them that information, which meant that my son’s medical team had less leverage with fucking Walgreens Alliance Prime RX, but I have zero regrets about keeping my son’s info away from big pharma.
posted by Maarika at 7:30 AM on June 5, 2020 [1 favorite]

You might ask the doctor to see if there is a mail order pharmacy that is "preferred" by the insurer.

Just chiming in to say often sleep medication (if this is what you are talking about) is not available for mail order because of its controlled status at least in the US. I still think this suggestion is a great idea but that may be both why this won't work and why the rest of this is such a pain in the ass.

My experience is that doctors are pretty unclear on both the status of insurance regarding prescriptions as well as which pharmacies can carry which medications in the case of medications that are not the sort of standard ones. The health care portal that my (rural) medical practice uses doesn't even actually list my pharmacy records, just the medications that I tell them I am taking or the ones I was prescribed. It's messy. Hopefully once you get a path through this it will be easier next time. I would also push for the simplest path through this and once you get the right doctor/pharmacy combination that you lean hard on them for making sure this goes more smoothly the next time.
posted by jessamyn at 8:54 AM on June 5, 2020

Best answer: The answers referring to the PBMs and prior authorizations are the right idea in general for this kind of situation, but there is another particular hurdle on this one specific prescription for your condition. There's only one FDA approved drug for non-24 so I am guessing the prescription is for Hetlioz/Tasimelteon which, according to their marketing site, "is not available at retail pharmacies" and they have a whole additional layer of bureaucracy between the prescriber and the pharmacy.
posted by ndfine at 9:26 AM on June 5, 2020 [1 favorite]

Response by poster: Thanks, all. I got a note from my doctor's office today saying that the prescription has been sent/filled by the specialty pharmacy, so now I guess I wait until I hear from someone about the insurance. I appreciate all the insights, and definitely hope this goes better next time.
posted by Alensin at 11:50 AM on June 5, 2020 [2 favorites]

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