The Tyranny of Drug Benefit Management & Chain Pharmacies

I received a call from a 35-year-old healthy strapping patient who was doing some yard work late in the afternoon, tried to straighten up and felt severe pain in his lower back radiating from his back to his buttocks and down his leg. It was after 5:00 p.m. and I was not in my office. After providing short-term instructions, I phoned his pharmacy and prescribed seven generic anti-inflammatory pills, a Medrol dose pack and a three-day supply of muscle relaxers.

When I made the initial phone call to this local branch of a pharmacy chain, I chose to speak to the pharmacist from the choices on their automated phone attendant. I held on for 10 minutes and no one answered so I hung up and called back choosing to leave a message for the pharmacist. I provided all the requested information requested, completed the order and then texted the patient.

One hour later his wife loaded their two young kids into their car seat and drove to the pharmacy. She drove into the drive through section and, when her turn came, was told no doctor had called in a prescription for her husband. She begged to differ and asked for the manager. Five minutes later she was told that they did have the order it was just not ready yet. They said it would take about one hour so she drove home.

As she pulled into her driveway, she received a text message that the medications were ready. She just put her kids back into their seats and drove back. Fifteen minutes later, at the drive through window, she was told that her drug benefit manager needed pre-authorization for the seven anti-inflammatory pills. Since it was now close to 7:00 p.m., and she knew I was not in the office, she asked if there was a phone number the doctor could call to obtain approval. She was told a note was faxed to the doctor’s office with instructions on who to contact and what information they were requesting.

The cost of seven generic anti-inflammatory pills was under $40. No one informed the patient’s wife that she could just pay for the medication and go home with it. The patient called me and explained the problem. He had the over-the-counter version of a similar medication at home so, I instructed him on how to take it until we worked it out. When I got into my office the next day, there were four separate fax sheets from the drugstore labeled first request through fourth for pre-authorization.

It should not be that hard to fill a generic non-controlled medication for a patient afterhours. No small private practice has the patient’s insurance information and their drug formulary with them and accessible all the time. I can probably access that information remotely from my tablet if I had my tablet with me but should I really have to carry it everywhere I go?

The insurer was not concerned about the insured’s pain. They knew if they denied it most individuals would foot the bill themselves and never ask the insurer to pay their fair portion. That, coupled with inappropriately high costs per pill, make the system a nightmare for patients and physicians alike.