This seems so simple – after all, why would your physician not know the name and location of your preferred pharmacy? But the reality may be different. While you expect to be asked at every visit by all physician offices to verify your insurance information, fewer offices routinely attempt to verify your pharmacy of choice. And if they do not know your preferred pharmacy, the consequences can be significant. Consider the case of Maria.

Maria’s Prescription Refill Nightmare

Maria is a 58 year old woman from suburban Philadelphia with a 10 year history of Meniere’s Disease, a chronic inner ear disorder characterized by spontaneous episodes of debilitating vertigo. While Maria follows a complete regimen for managing her condition, her ENT physician has prescribed Diazepam (Valium) to mediate her periodic attacks. When Maria feels the onset of an episode, she takes 2mg Diazepam, and the attack usually subsides after 20-30 minutes.

In the summer of 2012, Maria experienced several Meniere’s episodes while vacationing in North Carolina. When she realized that she had only a few doses of Diazepam left, she called her physician and arranged to pick up a prescription refill at a pharmacy near her vacation home. At the time, Maria did not know that her physician’s office changed her preferred pharmacy in her electronic medical record from her local pharmacy to the pharmacy 400 miles away in North Carolina.

A year later, Maria needed a new Diazepam prescription – she had used all of the refills on her previous prescription. Things did not go smoothly. Here is the chronology of what happened:

• Wednesday, August 14, 2013, 9AM – during a visit with her ENT physician, Maria’s physician told her that a new prescription would be sent to her pharmacy by his office; she probably would be able to pick it up later in the day. At 5PM, Maria visited her local pharmacy, but was informed that no such prescription had reached them.
• Thursday, August 15th, 9AM – Maria called her physician’s office. During the call, it was discovered that her prescription was sent electronically to the wrong location – in North Carolina. She was told by the physician’s office that a new prescription would be sent immediately to her local pharmacy. At 3PM, Maria visited her local pharmacy but was told that her health insurer would not allow the prescription to be filled because of the existence of an identical prescription at another pharmacy. At 4PM, Maria contacted her health insurer and explained her situation. She was told that several days would be required to clear up the confusion and the earliest she could pick up her Diazepam from her local pharmacy would be Wednesday, August 21st.
• Friday, August 16th, 9AM – Maria again called her health insurer, explained that she had not caused this problem and that she needed her medication in the event she experienced another Meniere’s episode. After researching the situation, her insurer’s customer service rep apologized for the inconvenience but reiterated that the earliest she could receive her prescription is August 21st. At 11AM, Maria again called her health insurer, had a similar experience with another customer service rep and asked to speak to a supervisor. The supervisor conveyed the same message – they are powerless to do anything about the situation, and she would not be able to receive her Diazepam until August 21st – a full week after the date that she had requested the prescription from her physician.

Discussion

What happened to Maria was the consequence of a health insurer refusing to override its operating systems and protocols when her situation required nothing more than a common sense solution. We wonder what her insurance company would have done if Maria needed insulin or another commonly recognized life-critical medication.

As consumers and patients, our challenge is to figure out how to overcome insurer systems and inflexible people who operate them in order to get what we need when we need it.

Step Up and be Your Own Health Advocate!

Maria’s experience could have been avoided completely if her ENT physician’s office had the correct name and address of her preferred pharmacy in their records. At a minimum, we suggest you verify the name/location of your preferred pharmacy at least annually with the offices of all physicians who provide care to you. In addition, we recommend that you verify this information following any of these events:

• If your physician office moves to a new location – all information does not necessarily accompany the move.
• If you are told that your physician office has installed a new medical records system – ditto.
• If, because of vacation or other reasons, you have a prescription filled by one of your physicians at a place other than your preferred local pharmacy.

And if you ever encounter a situation similar to Maria’s, consider doing what she did. She contacted her local health advocate on Sunday, August 18th. Then, armed with a basic understanding of how health insurer systems operate, plus a healthy dose of street smarts, she called the North Carolina pharmacy when they opened Monday morning, August 19th, explained the situation and followed up her call with a fax requesting immediate cancellation of her prescription. One hour later, the prescription at the North Carolina pharmacy had been cancelled and she reappeared at her local pharmacy. Her local pharmacist reentered her prescription, and it sailed through her pharmacy and health insurer systems as if there never had been a problem. Maria left her pharmacy with her Diazepam prescription in hand.

Nicely done, Maria.

Rick