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One of our clients called and was very upset that her new insurance carrier would not cover the prescription she was trying to pick up at the pharmacy. She had filled this particular prescription before the 30-day renewal date and could not understand how the new carrier knew this and was frustrated that they would not give her the drug she needed when she wanted to pick it up.

This has become an increasing problem for all of us and here is what we need to understand:

  1. There is a national data bank that houses all of our drug information including when each prescription was last filled. The insurance carriers access this data to limit drug abuse and to stay within the medical guidelines of the prescribing physician.
  2. In this client’s case the prescription was filled at the beginning of December and then again around the 20th of the month because December’s bad weather caused her to use more medicine than she normally would. She was fortunate that her pharmacist was able to override the 30-day limit and refill her prescription early.
  3. Administratively, this did not allow her to refill her next 30 days when she ran out around the 20th of January. Rather she had to wait until the first of February to get back on the 30 day prescribed schedule.
  4. We suggested that she call her physician’s office to ask if it was possible to produce a special short-term prescription. Otherwise, the doctor might have samples to help her get the extra few days of pills she needed.
  5. This client’s frustration is very common because we are accustomed to getting what we need when we need it. It appears as if the insurance companies are increasingly questioning physician-provided guidelines.

So, how did we get here? For years insurance carriers received premiums and paid out claims without much regard to their legitimacy or accuracy. Now carriers are increasingly looking in the drug arena for possible drug abuse. Additionally, pharmaceutical companies are upping drug costs with abandon and the insurance carriers have determined that the best way to control those costs is to carefully monitor distribution of prescription medication.

These two objectives are designed to keep us safe (or at least to not feed drug abuse) and to try to control prescription costs which are increasing astronomically in some cases and certainly are the cause of a significant part of our increased healthcare costs.

When we look at this issue objectively it seems very logical and we all need to connect the dots between dollars paid out in claims and increases in our premiums. Yet when we are the patient who needs medication immediately and we are unable to access the drugs required it can be hard to remain calm. Dealing with prescription claims is becoming increasingly difficult.

Contact us at Czajkowski Dumpel & Associates, Inc. if we can help you navigate the system!