Skip to main content

Pharmacy sued in prior authorization case

Jason Poquette RPh, BS Pharm

A recent Massachusetts Supreme Court decision is serving to remind pharmacies and physicians that communication about medications that are not covered is critical. The case involved the tragic death of a 19 year old girl with epilepsy whose insurance (MassHealth) denied a prescription for a seizure drug known as Topamax back in 2009. Because MassHealth denied the prescription, the woman could not obtain the medication which she had been taking regularly before, and this resulted in a series of seizures leading to her death.

As a parent my heart goes out to the family of this young lady.

Previous attempts to find fault with the pharmacy failed. But now the court has ruled the pharmacy has a “limited duty to take reasonable steps to notify” a patient and provider when a medication is not covered by the health plan.

The pharmacy involved was Walgreens. Apparently the patient’s family was told on several occasions that the pharmacy would notify the physician about the need for obtaining “prior authorization” for the requested medication. Such a notification could be done by phone or by FAX. It sounds like the Walgreens computer system at the time could generate an automatic notification to the provider as well.

No evidence could be provided which proves that this was done. The doctor’s office claims they received no such notification.

The bigger issue to me is that the court seems to have overlooked the real problem in this case, which was the insurance company denial of the claim to begin with. MassHealth [as do all insurance plans] sets the rules for when they will pay or deny a claim. A “prior authorization” is a tool used by insurance plans like MassHealth to save money for themselves on expensive medications. It is often a way to encourage patients or doctors into using less expensive drugs without taking into consideration the consequences of such denials. In this case the consequences were fatal.

Most insurance plans today actually try to prevent pharmacists from getting involved in the prior authorization process. If we try to call to obtain a form, we are usually confronted with “we will only give that to the doctor.” I usually respond to the health plan, with significant effort to be polite, that “this is my patient too. Send me the form so I can help get this process started!” But I’m typically met with resistance.

For now the court seems to be blind to any obligation or liability on the part of the health plan who actually denied the claim. Rather, they suggest the pharmacy (who gets no reimbursement for denied claims and no compensation for notifying a physician) is at least partially at fault. According to the Supreme Judicial Court “Pharmacists simply must take reasonable steps to notify patients and prescribing physicians that, if the physician wants a patient to receive insurance coverage for the prescribed medication, the physician must complete a form.”

So what should you do, as a patient, if the pharmacy tells you the prescription you need requires a Prior Authorization? Well, first of all, if the medication is a medical necessity, by all means let your doctor know about this. Don’t wait. Call your doctor. The pharmacy may contact them too, but you should reach out as soon as possible and let them know. If you need the medication immediately and cannot afford it, you should also call your insurance company and let them know.

This was a tragic case. Tragic for the young girl. Tragic for her family. And tragic that health plans (like MassHealth) are not held more accountable for denying care.