"It's not uncommon for insurance companies to deny a prescription, sometimes on appropriate grounds, such as a patient allergy that's listed on file or a dangerous drug-drug interaction..."

Dr. Goldhaber, I'm concerned that you don't know any of your local pharmacists! The statement above is an extremely rare discription of why a 3rd party insurance might reject a claim. In fact, the statement above assumes that the pharmacist didn't do their job (a small part of which is to screen for interactions and allergies on EVERY prescription dispensed). Hopefully they would contact your office before the suits do in those particular situations.

An insurance company will most often reject due formulary considerations... or for some irrational problem they have with the numbers, like you described with "Katrina." I have run into such appeal issues before in my anticoag clinic with variable success. Medicaid often will reject claims for enoxaparin if I have a patient requiring an odd dose such as 140mg. Since there is no such syringe size and the syringe barrels are not marked for wasting, orders are often written for 100mg syringes #5 and 40mg syringes #5. If left unchecked, Medicaid will ultimately reject one of the syringes and the patient will receive a suboptimal dose. In these cases I have called and discussed with a reviewer and they immediately overturn the rejection.

In another case, I have a patient with Factor V leiden and a true enoxaparin allergy (hives on 2 separate occassions). I had been covering him with fondaparinux when he went subtherapeutic on his warfarin in the past. His insurance dropped fondaparinux. He called me with an INR of 1.3, leg swelling, and a rejected claim. I called the insurance company and after 60 minutes of arguing they had no other options for me than to tell him to pay out of pocket (Arixtra is ~$140 per dose). Needless to say he ended up on heparin drip 2 days later. But a pharmacy benefits insurance doesn't really care... his hospitalization was on Medicare's tab, not theirs. 

Just a quick thought for you... While you wait for the insurance company to decide if they want "Katrina" to remain tachycardic or not, perhaps you could call "Katrina's" pharmacy and have the pharmacist dispense #45, cut fifteen Toprol XL 100mg in half, and dispense those tablets in a separate vial (due to the eyesight issue). Insurance is happy, "Katrina's" heart rate goes to the mid-60s, and no arguing with a suit! Use your RPh, Sam! They often have recommendations for insurance quandries.

Thank you for posting your comment on the Clot Blog.

I did contact Katrina's pharmacist, who gave her "extra" metoprolol 50 mg tablets while her "case" was being adjudicated.

But, is this really the way that healthcare providers like you and me should be spending our time?

Can't we put into place some sort of safeguards that prevent denails such as the one issued to Katrina?--SZG

Hi Dr. Goldhaber, I am a clinical pharmacist who manages patients on warfarin and assist with diabetes and lipid management at a large academic medical center. I also have past retail pharmacy experience, so I can provide some first hand experience to this topic. You bring up a great point in that it is a "waste of time" for the MD and PharmD to go back and forth to find a solution to "preferred drug" issues, especially since each insurance company has their own formulary. Patients are often unaware of this, so I often tell my patients to get a copy and carry it with them so that their physician will have some idea what is preferred and what is not. This results in a more proactive approach that seems to benefit all parties. More importantly, there needs to be a system change to improve this process. Retail pharmacists are well trained to counsel patients and assist with medication quandries, however, they spend an enormous amount of time dealing with such insurance issues as you outlined in your blog. The pharmacist is often stuck in the middle (AKA "the messenger") and is sometimes viewed negatively by the patient and provider because not everyone understands that it is not the pharmacist preventing them from getting the proper medication, it is the insurance company. I applaud you for bringing up this issue and I hope others do the same so that we can maybe one day improve the process for the well being of our patients and to prevent conflict between healthcare providers.

Thank you for your insightful comments.

 I hope that readers of the Clot Blog will be agents of change so that we can spend more time caring for our patients and less time dealing with the issues that confronted my patient, "Katrina."

 Health care reform should provide an opportunity for healthcare providers to mobilize and advocate for safe, effective, and patient-friendly prescription of medications.--SZG

Pharmacy managers and insurance deny prescriptions because of cost!  The would like you never to use anything but an ancient generic drug.  There are few medical indications for denial.  Note that what is denied this quarter may be preferred next quarter------because they got a lower price from another supplier.

 The insurance belongs to the patient-----not to the doctor.  I give the patient what is best for them.  If the insurance refuses to pay, I just inform the patient and let them solve it.  Not my problem.  I assume they came to me for the best care available.  I try to give them that.  That is frequently at odds with the goal of the insurance companies.

When considering the three x 50 mg Metoprolol, there would appear to be a loss of sustained release here. Why not 1 x Toprol XL 95mg + 1 x Toprol XL 47.5mg ( assuming these strengths are available in the US) instead of expecting the patient to break the higher strength tablets ?

Your reply to this blog is very sad.  Now we have Physician who does not give a darn for the well being of his patient.  I am amazed that you came out blunty and said you dont care if the pt is able to obtain your written rx's.  Shame on you.  Obviously you are in the medical field for the money.