What would you do in situations like this (Part 2)

[pharmtastic]

I would like to thank all of you who responded to my post in "What Woud You Do" part 1, you all contributed great ideas/comments. Now, this situation that I have faced several times may be less extreme than the methadone case but at the same time equally annoying.

A patient who brings in the script for a non-formulary drug refuses to accept/understand the reality and to cooperate with the staff for a solution.

For instance, a patient brought me an RX for Nexium which is not covered by her insurance (prefers to pay for Prilosec). Despite my vain effort explaining to her how similar they are and even my offering of calling the Dr right on the spot to make the change, she still insists on Nexium. Her reason: I need it. It's the only one that works for me but guess what, I won't pay for it.

Our conversation went in a circle like this.

Me (after several attempts to explain): M'am as I just explained your insurance will not pay for Nexium. Prilosec is the only choice they give you. It is very similar to Nexium, just like Coke and Pepsi (my favorite analogy), and I'm sure you will experience all the benefit of Nexium with Prilosec.

Customer: But it wont work for me. Nothing works for me but Nexium.

M: If you want only Nexium, then I'm afraid you will have to pay out of your pocket.

C: I cannot afford it. That's too much. Insurance will have to pay.

M: Your insurance already makes their decision not to. But you can always call them and see what they will do.

C: No, you do something. I need it.

M: The only thing I can do is calling your Dr to make a substitution.

C: Then they will pay for it, right?

M: M'am I just explained to you three times that...

What would you do in situations like this?

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[confettiflyer]

Arguing would be a waste of time (and consequently money). Fill the Nexium, make them pay for it, end of story. Offer to call the physician only once.

If they insist Nexium be "covered," just shrug and say it's out of your hands...talk to your insurance. Next patient please.

 

[MountainPharmD]

This happens at my pharmacy all the time. I work at a pharmacy where 3/4 of my patients are over 80. I have a great deal of respect for this generation but they are a pain in the butt to deal with. Sir, your medicine is more this month because you are in the doughnut hole. Huh?!?! Sonny I don't want to buy any doughnuts I need my medicine. And around and around we go.

I always make it clear to the patient who is responsible. If it is a PAR I stress over and over it is the doctor who has to do it and not us, so call the doctor if you have a problem with how long it is taking.

Likewise on not covered medications. I tell them it is the insurance company who does not want to pay. If they have a problem they need to call the insurance company. Occasionally we get the "I don't understand why YOU won't give me my medication." In this case I get the medication put it in front of them and tell them here is you medicine. You can have it for $160.00 right now.

 

[AngelaCL]

What about offering to call for a prior authorization? Usually when we get a rejection for Prevacid/Nexium the message calls for a PA - it is then up to the doctor to either change the medication or deal with the insurance company.

It sounds like you are too nice to your customers - if you have explained everything to them and given them options (pay for the med, wait for a PA, get the doc to write a new Rx) and they refuse to listen, you've done all you can. There are no magic words you can say to make the patient cooperative or to make the product get covered. Walk away and move on to the next patient.

 

[bananaface]

You could call to find out if a PA is possible and under what circumstances. "Nothing works for me but Nexium" implies that she may have tried and failed other drugs. If those have been filled through her current insurance you might be able to get a PA over the phone. If they are documented at her doctor's maybe you could have the doctor call/fax for PA. Or, maybe they just plain won't do a PA for Nexium.

When all else fails you could dial the insurance company's customer service department and let her talk to them directly.

 

[acetyl]

Your insurance won't cover this drug. We'll sell it to you for ~$160.

If they ask why, tell them why, ask to see their insurance card, then tell them to call their benefits office and ask why. The insurance company always knows more about their insurance than we do...well, not always

 

[confettiflyer]

When all else fails you could dial the insurance company's customer service department and let her talk to them directly.

Waste of time and waste of money. Have the patient call on their own time/own phone and not take up your station.

 

[bananaface]

Waste of time and waste of money. Have the patient call on their own time/own phone and not take up your station.

If they are not understanding or refusing to acknowledge the situation, it is a way to resolve that problem in-house.

 

[confettiflyer]

I encountered these problems at least once a day (more in January/February). I would strictly stick to the "talk to your insurance" line for the sake of my coworkers and for the sake of the 8 other people in line behind that person.

Taking up your pharmacy's time to solve their insurance problem is an unfair burden to place on everyone else. Slightly heartless...but necessary. Their formulary is not for us to battle, save for a PA request.

 

[BidingMyTime]

You explained multiple times their insurance won't pay for Nexium. You explained their options of paying cash or using a same-class alternative. Pt doesn't like those options. I would then be blunt and tell her there is nothing else you can do, and that you would be happy to transfer her prescription to any other pharmacy. Because at that point, that is all that you can do for her.

 

[pharmkelly]

One of my favourite:
I can not negociate with your insurance.

 

[imperial frog]

Just like before, I don't see the problem...other than the one that you seem to keep bringing upon yourself. The patient only has 5 options at this point; pay (not your problem), don't pay (not your problem), see if the doctor can get a need override (not your problem once you send him/her a fax stating the issue), accept a substitute (not your problem), or contact the insurance company herself (not your problem). If you contact the insurance company and they won't play ball...it's out of your hands.

Unless you want to play the martyr, there's no reason why you need to keep doing the back and forth that you seem to constantly get into. Those other customers lining up behind her need help too.

I would like to thank all of you who responded to my post in "What Woud You Do" part 1, you all contributed great ideas/comments. Now, this situation that I have faced several times may be less extreme than the methadone case but at the same time equally annoying.

A patient who brings in the script for a non-formulary drug refuses to accept/understand the reality and to cooperate with the staff for a solution.
?

 

[Pharmer_Andy]

I agree best bet is for a Prior Auth. Maybe refer her to her MD to get some samples while the PA is pending. If Prior Auth is denied and she doesnt want to pay for it then thats her decision. If her GERD is really bad she maybe she will be swayed to try another PPI. Protonix is now generic maybe thats a viable cost friendly option.