We serve a patient with severe mental disabilities living in a group home. He has full time staff assisting him with his medications. Our pharmacy provides the patient’s medications packaged to meet the rules and regulations for this type of residential care facility. These packaged medications are delivered in monthly installments.
The prescription drug plan the patient uses made some changes with the new year, and one specific change created a problem. With the new year, one important medications now requires a prior authorization. The appropriate paperwork was initiated immediately, with our pharmacy providing much of the basic information directly to the physician to be submitted. This included the quantity needed and the need for a 31 day day-supply as is required for the group home’s monthly delivery of packaged medications.
At this point it is important to note that the medication was delivered to the facility before the first day of the month to the group home. Billing could not be done until the first day of the month and until that point it was not known that a prior authorization would now be needed. We went out of our way to ensure that the patient would not be without the medications they required.
Five days after submitting the prior authorization, approval was granted. When our staff went to bill the medication that had already been delivered and was already being used, they once again received a reject. The insurance, despite the approved prior authorization, would only pay for a 30 day supply of the medication.
For most members of this drug plan, this would not a problem. But in the case of our group home resident, this change creates a logistical issue. Some months, including January, have 31 days in them.
This is where the painful part of the story starts. Talking with the Prior Auth department of the plan we were told that they could not approve more than a 30 day supply. They suggested calling the customer service phone number and asking an exception to be granted. As I was trying to support the group home staff and care for my patient, I did as asked.
During this call I was shuttled to multiple departments. Eventually I spoke with someone that appeared to understand the issue and was going to get me to someone who could help. Once I got there, however, I ran into a brick wall. I wish I could say that this was unexpected.
My request was simple. Put an exception into place to allow a 31 day supply of the drug. I was told that because I was the pharmacist and not the prescriber or the patient that I could not do this. Those that know me will immediately recognize that this upsets me. I continued the call, escalating to a supervisor who simply read off their cue cards the same information. It was not until I mentioned that I was going to complain to CMS that something changed.
After hearing me threaten to complain to CMS, I was put on hold. When they cam back, I was returned to the technician who immediately began to attempt to fix the problem. Her attempt to put the exception in place required her to make some of the same calls I previously made during this process. I noted with some satisfaction that she had difficulty negotiating the same phone tree prompts I have been using over the past two hours. During this process, she was disconnected from both her own company’s phone tree, and from me.
After spending over 120 minutes on the phone I now have to start over: I was back at square one.
Patient care is not only complex from a medication perspective, but also because of the need to jump through arbitrary hoops imposed by the health plans and their benefit managers. We are very aware that in caring for our patients, one size does not fit all. Unfortunately, many healthcare plans and their pharmacy benefit managers do not seem capable of understanding this concept. Our patients are not just faceless nondescript beings. They are living, breathing individuals. We need to ensure that they are achieving their therapeutic outcomes. We need to ensure they are getting the best possible benefit from the healthcare dollars that are being spent on their behalf.
The problem as I see it is that the plans, to a large extent, have failed to comprehend the larger picture. They have allowed the PBMs to describe the benefits of pharmacy only in terms of drug spend. With their focus on the drug product, and not on care and outcomes, the patient and the plan lose.
It is time for the plans and their benefit managers to start working to be a part of the solution, and not be a part of the problem.
Remember, caring for patients is not easy. You may not succeed every time, but don’t give up. Make Every Encounter Count
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