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Getting a Prescription Refill: Hassles from My Health Plan

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In a recent post entitled “The Joys of Health Insurance Bureaucracy” I described how it took me (a physician) over three months to get one common prescription filled through my new health insurance plan. Of note, I have still been unable to enroll in the prescription refill mail order service that saves my insurer money and (ostensibly) enhances my convenience. The prescription benefits manager (PBM) has lost three of my physician’s prescriptions sent to them by fax, and, as a next step, has emailed me instructions to complete an online form so that they have permission to contact my physician directly (to confirm the year’s refills). Unfortunately, page one of the form requires you to fill in your drug name and match it to their database’s list before you can continue to page two. For reasons I can’t understand, my common drug is not in their database. Therefore, I am unable to comply with my insurer’s wish that I enroll in mail order prescription refills. This will further delay receipt of my medication – and probably increase my cost – as I will be penalized for not opting into the “preferred” mail order refill process.


Now, all of this is infuriating enough on its own, but the larger concern that I have is this: How many patients are not “compliant” with their medication regimen because of problems/delays with their health insurer or PBM? Physicians are being held accountable for their patients’ medication compliance rates, even receiving lower compensation for patients who don’t reach certain goals. This is called “pay-for-performance” and it’s meant to incentivize physicians to be more aggressive with patient follow up so that people stay healthier. But all the follow up in the world isn’t going to get patient X to take their medicine each day if their health insurer or PBM makes it impossible for them to get it in the first place. And shouldn’t there be consequences for such excessive red tape? Who is holding the insurers and PBMs accountable for their inefficiencies that prevent patients from getting their medicines in a timely manner?


Pay-for-performance assumes that physicians are the only health care influencers in the patient compliance cycle. I’ve learned that we only play a part in helping people stay on the best path for their health. Other key players can derail our best intentions, and it’s high time that we look at the poor performance of health insurers and PBMs as they often block (with intentional bureaucracy) our patients from getting the medicine they need. While insurers save money by having patients struggle to get their prescriptions filled, doctors are payed less when patients don’t take their medicines.


Not a great time to be a doctor or a patient…or both.

More Blog Posts by Val Jones

author bio

Val Jones, M.D., is a Board Certified rehabilitation medicine specialist licensed to practice in 6 states (NY, CA, DC, MD, SC and VA). She is a 2001 graduate of Columbia University College of Physicians and Surgeons, and the CEO of Better Health, LLC, a medical blogging network. For more of Val Jones’ posts visit Better Health or follow her on Twitter @drval.


Tags for this article:
Prescription Drugs   Health Insurance   Inside Healthcare  




Comments on this post
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Andy3155 says
April 24, 2013 at 11:35 AM

Over the years, I have come to realize that refilling a prescription is more of a hassle than buying a new car. Some times, when my Diovan HCT (hypertension) prescription expires and I need to refill it, my local CVS Pharmacy makes me feel like some pill popping crook. I kid you not! To top it all off, with all the technology that's out there, my local CVS Pharmacy can't even get it together enough to remind me that my prescription is about to expire and that I should schedule an appointment with my doctor to have it renewed.

JBAR says
August 27, 2013 at 2:46 PM

This is my personal experience and opinion. I have to interest in any companies. I have to handle a ton of medications for my family. Express Scrips have been my savior. Express Scripts has automatic refills and notifies you that your prescription will expire. They also have excellent on-line and mobile apps. Many medical facilites use them and can interface with them directly/electronically. Even if not, they can call/fax them and get quick turnarounds. They allow 3 months worth of deliveries at a time. I have had an excellent experience with them.

Angela Stewart says
April 1, 2014 at 5:15 PM

Dr. Jones,

I guess I would fall into the category of "soon to be non-compliant" with my medications for hypertension and Type 2 diabetes. Having dealt with lost mailorder prescriptions, delayed processing with CVS "Care"Mark as required by my insurance provider (Cigna) and finally switching to a local CVS (which has resulted in no end of prescriptions being lost or misdirected even when entered on their website or smartphone app), I must say I have had enough.

I've never in six years considered not taking my medication. In fact, I'm one of those who will return home if I've forgotten to take it. But I just completed yet another phone call to CVS due to an issue between my physicians office and them. Once the customer service rep at CVS began the spiel of "you need to contact your physician..." I reminded them that I was paying them for a service, not for the privilege of being the go between.

I find it strange that physicians and insurance companies lament patients who are not compliant, yet promulgate processes which seem to discourage that very compliance.



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