Please enjoy a brief digression from the usual focus on learning. This is a great anecdote and illustrates some of the confusion in our current healthcare system.
The healthcare system is like a giant jigsaw puzzle and it can be very confusing to put all the pieces together.
A friend was talking about prescription insurance challenges she is engaged in when working in a community pharmacy. Occasionally, a patient is unable to get a medication because the insurance does not cover it. The misperception is that Pharmacists in the community are the cause of this limitation in access – this denial of something that can be of great importance to us as a medication.
However, Pharmacists are in the middle…of a few systems. They get the prescription from the doctor – but – that does not mean the insurance will cover it. That medication claim is submitted to the insurance and the insurance decides if they will cover it. This second interaction is with the insurance. The last is with the customer and if the medication is not covered, it’s the pharmacist or pharmacy technician who tells the customer the insurance is not paying for it. It’s a frustrating place to be, on both sides.
The (very) basic process is:
Doctor/APRN/PA -> sends prescription to pharmacy -> pharmacy submits to insurance
From there, the insurance accepts or denies the claim, based on a pre-approved list of medications, called a formulary.
Some doctor’s offices have begun to get realtime coverage of medications, which helps to reduce the risk of a medication not being covered but the majority do not use this technology yet.
From a patient’s perspective, there are important questions you can ask. Setting aside questions related to interactions and side effects with new medications, one question is “will the insurance cover this medication?” If not, the doctor will find an alternative. Better to figure this out earlier and save yourself frustration later on.