Who is responsible for finding out if a patients prescription drug will be covered by insurance?
Example: I am a technician in a doctors office and I call in Rx medications frequently. Recently, after calling in some prescriptions for a patient, I got a fax from the pharmacy stating that the drops would need prior authorization from their insurance. Since I had never been asked to do this before, I simply stated that we could call in substitutions, which are basically generics. The pharmacist asked if they would be covered by insurance and I stated that I would not know that. He became very upset & rudely implied that I was not interested in customer care and that he would do it himself.
Finding out if a medication is covered by an insurance company is something of a cooperative effort in our current outpatient system.
A doctor's office "could" contact the health plan and get the information regarding formulary status.
A pharmacy could simply try to "run" the prescription when they receive it, and thus determine the status. If rejected, the pharmacy "could" contact the insurance company for a covered alternative.
A patient can always call the "800" number on the back of their card and inquire about the formulary status of a drug, and inquire about alternatives.
The pharmacist you encountered sounded frustrated. The challenge is that the pharmacy is under tremendous pressure already just to keep up with the fill volume. Many pharmacies see 500-1000 patients per day. A single prescription drug often nets a profit of $2.00 or $3.00 to a pharmacy, sometimes a bit more. A phone call to an insurance company can take 20 minutes. Mathematically it just doesn't work.
Good question. We all need to work together. The patient's health is our common goal. Getting there we find a few bumps in the road.
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