The Future is Scripted

Future Scripts (https://www.futurescripts.com/FutureScripts/) is another pharmacy benefits management company that services Personal Choice and Keystone Health Plan, Independence Blue Cross products. In general, pharmacy benefits management companies serve one purpose – to manage your prescriptions. They typically consist of a mail order branch, which, for Future Scripts, is now Catamaran when it also used to be called Future Scripts, and the “management” branch, which mostly refers to the prior authorization department. Or, put differently, we can call that the treatment denial department. Prior authorizations are becoming increasingly stringent and what is allowed far more restricted. It seems that these companies utilize a number of different strategies. One is to inform patients that “we contacted your doctor and have not heard anything back.” This is often the furthest from the truth but is, I believe, part of the overall script of denial and delay. The longer something is not paid for, the longer the money sits in the coffers of the insurance company. Their latest wrinkle in delaying care was a bit more insidious than the usual denial.

Last week I prescribed a newer antidepressant for a patient. Previously she had been receiving samples but I had run out. She just got insurance and the luck of the draw gave us Future Scripts as the manager. I submitted the prior authorization request without prompting, knowing it would be required. I used their general prior authorization form. I received a call back asking if I was also requesting a tiering exception (which would lower my patient’s copay). There was no option for that on the existing form so I called the number (I dread calling because it is always a waste of my time on the phone). It rang – I counted – 40 times, no answer. Thinking perhaps I had used the wrong number I called again, same result. The third call I placed a pushed an option to speak to an agent and was routed to Catamaran, the mail order pharmacy, and they of course knew nothing about this case nor could they even locate my patient in “the system” using her name, date of birth and insurance ID number! Frustrated beyond belief, I created my own tiering exception form from one of their existing forms and faxed that in before leaving the office. The next day, the same woman who had left me the message about the tiering exception called again. This time when I called back she answered and I vented my frustration. She only added to it by telling me a different technician must have received the second form. She admitted they have NO VOICE MAIL for their extensions, which is why it rang 40 times twice. She also told me that the form I had initially submitted that she saw was actually the correct form for tiering exceptions too but it had no place to ask for that! Frustration comingled with bewilderment at this array of alarming information. After venting some more I informed her that if the medication was not approved WITH a tiering exception by the end of the business day I would file a grievance with the state insurance commission. Magically, both the medication itself and the tiering exception were approved, though of course not before wasting two separate fax transmissions to me to inform me of this. MY patient’s care was delayed nearly a week as a result of this.

And just this week, another company added their special brand of planned incompetence. Aetna (https://www.aetna.com/individuals-families/members-pharmacy-prescription-benefits.html) requested a prior authorization for a patient’s generic Concerta (methylphenidate ER, an ADHD medication). I submitted a request on an Aetna form, but received a phone call informing me an attempt to fax me had failed. I checked the fax log first and it hadn’t failed. My sense of foreboding began to rise. I filled out the newly faxed authorization form and one of the questions I had to answer was the following:

Does the patient have documentation fo symptoms significantly impacting, impairing, or compromising the patient’s ability to function normally (ie., attend/maintain academic enrollment or employment)?

The answer I gave was yes. It was clearly noted, as the box for yes was filled in while the box for no was left blank. I received a faxed back reply with the following reason given for a treatment denial:

The information did not show that you have symptoms significantly impacting, impairing or compromising your ability to function normally as listed below.

There was no list of symptoms below that. I faxed back with a letter explaining that I had already answered yes to that question and demanding a reason for the denial. Again, I was forced to call to speak with a pharmacist, as the technicians who call are not permitted to render decisions but simply gather information from me while reading from some scripted algorithm before handing me off to the pharmacist, who asks all the same questions. Again, a threat of the state insurance commission along with a threat of legal action this time produced a swift reversal of the decision, but no explanation for the denial after the one question on which the denial had been based had actually been answered affirmatively.

If you are a patient reading this, you may have had similar experiences. Hopefully your doctor will go to bat for you or has office staff to do that. If not, you do have recourse by filing a grievance with your state’s insurance commission and by trying to find a law firm that specializes in managed care, or mangled care, as I like to call it.

National Association of Insurance Commissioners: http://www.naic.org/state_web_map.htm