I just never know what is going to show up in my INBOX.. Apparently this little piece is fresh off the digital presses from apparently late yesterday or early this AM.
Back in Dec 2017 I had this post on my blog CVS Pharmacy Will Limit Prescriptions for Opioids Apparently those who have Caremark as the prescription PBM and close to have their prescriptions filled at a CVS Pharmacy may be the most impacted.
We have a serious – and growing – Pharmacists surplus… so it would not be out of character for CVS to tell their Pharmacists to follow the edicts of Caremark or they could/will be fired..
What this CVS edict appears to be mandating for their employed pharmacists to do better documentation of DUR (Drug Utilization Reviews) in their pharmacy computer system.
I am sorry that the text in the “ACCEPTABLE” column is unreadable, but I could not figure out how to make a clearer copy from the one that showed up in my inbox. I can tell you that the bottom two texts examples were dealing with controlled substances.
I have been told that some pts that have had their controls denied by insurance are paying cash. While this may be plausible on the first rejection… the DEA has always stated that a pt paying cash for controls when they have insurance is a RED FLAG
We don’t know what databases that the DEA as access to. I do know that there are databases out there that have nothing to do with the states’ PMP that will show what medications a prescriber has written and was filled at a pharmacy.
We do not know if the various states’ PMP can/will produce reports for the DEA divulging what pts are getting controls and paying cash while they have insurance paying for other medications.. also providing prescriber and pt’s name and address.
No one knows if the DEA will “excuse” those pts that has insurance but the insurance company refuses to pay for controlled meds in particular.
IMO, any pts that is forced to pay cash for denied controlled meds should submit their receipt to the insurance for reimbursement. There is also a number of paths to appeal the denial. The insurance doesn’t have to tell you about the appeal process – UNLESS YOU ASK – then they have to give you the process in writing – now a days probably a website … follow the process BY THE LETTER .. don’t miss time deadlines to follow up.. there could be as many as three levels of appeals.. Just figure that the person/committee who created the criteria for the first denial is probably who is doing the first appeal… so one can expect a denial on your first appeal…
Remember, the insurance company is paid monthly premiums – by someone – to provide necessary medical care and by denying it.. the continue to collect those premiums and don’t have to pay out for the necessary medical care – they end up with MORE MONEY ON THEIR BOTTOM LINE.
Filed under: General Problems
States vary of the agencies and offices that have access to their PMP without officially requesting it. If a request is denied. The agency or office might be able to obtain a warrant through the courts.
Caremark/CVS is doing their best to bunny foo foo the public. Let’s just say I went straight to appeals (THEY called my dr the next day, on a Monday, at 8am as soon as he got in and took care of the NOW needed authorization I didn’t need for the past 7yrs). DO NOT let them push you around. Tell them “if my med does not get filled I WILL go into withdrawals, it WILL affect my health, I WILL end up in the ER, and if I have a STROKE, SEIZURE, OR MI, it WILL be your fault and cost my insurance MORE money. NOW YOU WILL FIX THIS B/C YOU are the reason I am in this predictament. Or I CAN get a lawyer involved and YOU WILL be doing damage control all over social media. I AM DONE with CVS/Caremark’s BS, in 17yrs I’ve NEVER overdosed, had a medical emergency from taking my legally prescribed opiate medication, and NOW it’s an issue? Also let them know You will include Dr Brennan in that lawsuit, he’s the CVS/Caremark dr that has illegally decided what dose our opiate medication should be. He’s never seen us, examined us, or seen our records, he had NO LEGAL RIGHTS to change our medication or dose. STAND UP FOR YOUR RIGHTS OR THIS WILL GET WORSE. ❤️❤️. P.S. I love it when they think they know more than I do about meds then I have to tell them not only was I an ICU RN but I also know my state laws regarding opiate prescribing AND I also know my rights. They HATE that , oh well!!!
When a patient gets a,prescription(s) for a medication that might lead to physical dependency. The patient accepts the risks of that medication. That includes the risk of suddenly no longer having access to that medication. There are no laws guaranteeing any patient access to any drug.
Threatening to sue often backfires. Pharmacies, insurance companies, etc are aware no law guarantees a patient to a particular medication. Patients can be flagged as drug seekers, irrational, etc. Unofficially, pharmacists and pharmacy staff talk with other pharmacies in the area. These pharmacies are owned by different companies or individuals. Being difficult can result in few, if any, pharmacies wanting to deal with a patient.
Patients need to appeal denials. And if needed, take the appeal as far as possible. But, an appeal is not the same as threats of a lawsuit. If you really think you have a case. Go talk to an attorney. Just be prepared to not find one that will take the case.
The basic reason that no attorney can be found is that in our judicial system the “value of life” of someone who is handicapped/disabled, elderly, unemployable, retired is somewhere near the value of the family pet “ZERO”.. so there is no potential upside for the law firm, also most states have award limits… some as low as $250,000 and again no financial upside for the law firm. If the client has the ability to pay out of pocket for a lawsuit.. .I am sure that there are numerous law firms willing to take the case
Each state has requirements that must be met for lawsuits to proceed. A person believing they or a loved one has been wronged. Is not enough for a,lawsuit to proceed. That in why attorneys will not take cases like this. Attorneys know there is no basis for a,lawsuit.
Patients have a certain level of responsible for their health. They cannot always blame others when things do not go the way they think they should.
If my pharmacy refuses to fill my Welbutrin, or my propafenone for a reason within their control, and I shoot myself in their store or go into afib or PVCs and die on the spot, the store has no respomsibility?? Being out of the medication is one situation, refusing to fill a legit RX can harm the patient. And when my indie pharmacy is out of a med, they always ask what I need til they get it in. They transfer or borrow my meds because they have a responsibility.
So, NO, I do not accept that we patients understand we can be “cut off” any time someone feels like it. Not a medical pro. My MDs put me in hospitals for quick med changes, or taper off slowly.
Even pain clinics by law must issue a 30 day RX to departing patients.
Everyone HAS an ETHICAL responsibility. And I think any chain will panic if PTS start keeling over , seizures, suicides, major med events just because a chemist with ZERO medical residency or school wants to play Dirty Harry against the “opioid epidemic” BS!!!!
People sre suffering, in agony, killing themselves….if that ain’t enough reason, y’all ain’t human.
No law states pain clinics must give patients a 30 day prescription when discharging them.
Only certain drugs are considered life saving medications. Opiates are Not one of them. I know many pain patients and others,say they are. But that does not change the fact opiates are not classified ask life saving drugs.
cold turkey withdrawal from opiates can cause a hypertensive crisis… which could lead to a stroke and/or death. Cold turkey withdrawal from benzos can be FATAL.. Of course, pt abandonment can cause legal consequences from the prescriber throwing a pt into cold turkey withdrawal https://www.pharmaciststeve.com/?p=15358
Please provide links to medical malpractice law suits won because a doctor would not prescribe opiates. I look forward to reading them.
Prior Authorization is not the same as an appeal. It is up to each insurance company to decide the medications they require a PA for.