A Question of Dosing
How much oversight and management of prescription benefits represents an overdose? I received an e-mail today from a patient informing me that his insurance prescription benefits company, Express Scripts (formerly Medco) https://www.express-scripts.com/ canceled two of his antidepressant prescriptions because there was a question of the dosing. This patient has been on high doses of both since 1999 and has been stable taking these drugs with no side effects or negative consequences. Express Scripts tried to contact me last week but I was away on vacation. So instead of trying again the following week (my answering service provided information that I was away on vacation), the company simply canceled the prescriptions and told my patient of that decision. I then was required to call Express Scripts to rectify the situation and after 20 minutes or so on the phone the situation was resolved.
On the surface of things, this does not seem like such a big deal, does it? It happens all the time, right? It’s just a part of how modern medicine operates. So let me take you through the actual process. I called, a technician answered, told me what the problem was after asking me all the proper identifying information about the patient, then said she would transfer me to the physician line so I could speak with a pharmacist. So what did she do? She promptly transferred me right back to the same line I initially called, and I had to repeat the whole process. Again, I gave all the identifying information, explained the situation, and the man who had answered this time asked if I wanted him to take the prescription or wanted to speak with a pharmacist. I asked if I would have to speak with a pharmacist anyway, and he told me yes. Of note is that though I had volunteered all the proper identifying information right away, he still asked me separately for each bit of data as if he had not heard a thing I said. I gave the zip code THREE times before it sunk in. Of course, I chose to speak with the pharmacist, who cheerfully answered her line. I demanded in writing where her company has the right to override a physician’s orders without authorization from the physician. She told me she does not have it in writing anywhere and therefore couldn’t provide that but that if the company has a question about the medication, such as the dose, and cannot get in touch with the physician, the company can then cancel the prescription!
I have written in previous blogs about the need for insurance companies to be monitored or regulated in some way. When I began my practice in 1993, there were no three month prescriptions nor was the market saturated with pharmacy benefits management companies (PBM’s). Patients went to their local pharmacy and got their prescriptions. If there was a question, the pharmacist would call the doctor and in the event the doctor was not available, unless there was a dangerous possible outcome from the drug or its combination with other medications, the pharmacist would give a partial prescription pending discussion with the physician if there was still any question. Now, the patient is completely taken out of the loop until he or she is informed that the prescription has been canceled. Again, it is the patient’s needs that are considered last. In the case of this patient, the prescription benefits company was formerly Medco, but Medco was purchased by Express Scripts. One would think that there would have been access to data from the previous company and previous policy database so that there would have been continuity and therefore access to data stating that the patient had been on these two medications at the same high dosage since 1999! Instead, I was told that each time a policy changes the same thing will happen. I also found it very frustrating that the pharmacist requested the same identifying data that her technician had already been given, as if the previous information was sucked out in some benefits management vacuum, lost on some other computer screen in a parallel universe. If I want to be truly cynical, I’d say that the higher doses are also more expensive for the insurance company, though these days it’s hard to separate cynicism from the actual reality behind such decisions, as pharmacy benefits companies exist primarily to save the insurance company money.
If this has happened to your prescriptions, remember to send a grievance to your state’s insurance commissioner. Again, you can find that information on your state’s website. You can also talk to your employer if you are not satisfied with how your insurance company handles your claims, prescriptions, etc. This is not how modern medicine was meant to have to operate.