I am just as frustrated as you are about your drug formulary plan. I evaluate your needs and prescribe the most effective medication for your condition. I make every effort to check your plan to see what is on your formulary but this is often not available or changes frequently.
When I get notification from the pharmacy that the medication I prescribed is not on your formulary, very often they offer no alternatives. If an alternative is stated, many times it is a medication that does not meet your needs. For example, I may prescribe estrogen for vaginal dryness and the response I receive will recommend a medication for osteoporosis.
Sometimes I get a letter that is usually four pages long and begins by saying that you have received a temporary supply of the medication I prescribed. Next, there are statements about how the drug either isn’t on your formulary or the quantity exceeds the plan limits. None of these letters contain a reference to an online formulary physicians can access to compare the covered alternatives.
So what do I do as your physician? These are the steps we take:
1. My staff calls you to let you know that your prescription has been denied (you probably already know this and have been waiting at the pharmacy) and ask if you have access to your formulary.
2. My staff calls the pharmacy to see if they have the formulary and I evaluate the alternatives. Often I have to switch you to some older and less effective medication because it is cheaper.
3. Then, my nurse calls you back to see if you want to pay for the medication or try a less effective medication that is covered by your plan.
4. Next, I have you try the less effective medication and hope that it works. If it is not effective, my staff will spend a lot of time calling your health plan and being put on hold for twenty minutes listening to bad music.
5. The alternative is filling out cumbersome forms in hopes that you will get your medication. This is most likely denied unless you have tried the less effective and cheaper alternatives.
It is difficult to believe that these “Megapharms” do not have a more efficient way for physicians to prescribe your medications. Why do they waste paper and postage on letters that say what is not covered without providing us with a list of medications that are covered? I will make an educated guess that the purpose of this complicated maze is that they do not have to pay for your medication.
Yes, dear patient, I am just as frustrated as you are.
Dr. Paula Dhanda is a practicing physician in Kelseyville. She is the founder of Worldwide Healing Hands. She may be reached at 279-8733 or visit https://drspecialtycare.com or http://www.worldwidehealinghands.org.
Published in the Lake County Record Bee: Healing Hands: Frustrations with formularies