Why do pharmacies, doctors, and insurers do these things?

Factual Questions
1

Trying to avoid a rant, here; I try not to get angry at policies if they have a rational basis to them. Hence, while I’m going to describe things that annoy me, I’m trying to determine whether my annoyance is outweighed by a benefit to society.

To whit:

-Why do insurers frequently demand “prior authorization” before paying for a prescription? I’ve had this happen at lezst ten times over the years. In each case, I’ve had to get the prescribing doctor to fill out a form (which appears to simply reiterate the need for the prescription), and fax it in (or call the insurer). They do this, the insurer accepts it, the prescription is filled. On a few occasions, I’ve had this happen at times when the doctor couldn’t be reached. I suspect that the insurers do this in an attempt to avoid paying by creating a confusing and potentially difficult situation for the patient; is there a reason beyond cutting costs?

-Why do pharmacists not maintain a searchable database of their inventory? I have a medication which requires fills every two weeks. Its a controlleld substance. I’ve finally gotten my local pharmacy to keep this on-hand in a reliable way; however, for a long time (many months, at least), it was a gamble whether I could find it at a local pharmacy. There are something liike 8 CVS/pharmacies in my small city; they’re able to check my insurance information and purchase history in ANY CVS nationwide. However, when checking whether they have this med in stock, they have to send someone to the locked-down controlled substance area, the person has to (apparently) root through a binder, maybe fish around in a safe, and it ends up taking at least five minutes to determine whether they have it. If they don’t, they sometimes offer to check another CVS; this requires calling, waiting on the phone for a qualified person, then waiting at least another five minutes for the person at the other store to manually do the same thing – check the physical existence of the stock. Its often literally faster to drive to five stores than to attempt calling and verifying. My question: WHY CAN’T THEY MAINTAIN AN INVENTORY DATABASE? They already have a database (nationwide!) of everyone’s insurance information; surely, they’re required to maintain some sort of inventory on controlled substances to ensure there’s no diversion or theft going on. I see no way that such a database provides a security or fraud risk; it would simply state what a store believed they had in stock, so customers looking for hard-to-find products could be directed to the right place. I have to assume this is something done for legal or liability reasons, but I can’t see where the problem lies.

I felt like I had another one or two; if I think, I’ll mention them. I apologize if this came off as a rant, but I truly want to know if these kinds of things are necessary evils of the healthcare system, or if they are things which could be changed (and whether I should work to bring them to the attention of those with the power to change them). Thanks.

2

Insurance companies require prior auths on medications they don’t “want” to pay for, but that they will if it is needed. The most common times there is a requirement for a prior auth is if there is another drug that will treat the condition. They will normally require you to try the cheaper drug before they will pay for the more expensive one. One example is when the doctor writes for a Proton-Pump-Inhibitor like Nexium (which is brand only), and they require you to get a prior auth, or try another PPI like Prilosec (has a generic). The other major time I see it is when the dose is higher then the normally prescribed dosages.

Why do they do it? Because it works. Many times a doctors office will change the medication to something different that is covered instead of going through the hassle of getting a prior auth. Pretty much your insurance company is asking the doctor if you REALLY need this particular drug.

From the way you said it, it sounds like you have a CII script. There are certain special requirements when filling CIIs, mainly that we are not allowed to partial them (well, we can, but we don’t like to because of the legal requirements if we partial). We also keep a perpetual inventory in a book that shows exactly how much of the medications we have. They aren’t actually going into the CII cabinet, but going to look at that book, and making sure we have the exact quantity available. I don’t know about CVS, but at the pharmacy I work at, the book is always correct, while the computer system’s inventory lags. We don’t want to tell you we have the drug when we actually don’t.

One little thing though, most pharmacies will not tell you what CII’s they have in stock over the phone if they don’t know you. If you called me, and I didn’t know who you were, and you ask if we had so-and-so CII drug in stock, I would put you on hold for a few minutes, continue whatever I was doing, then come back on and tell you we didn’t have it, without even checking. We do this because there have been way to many robberies on pharmacies trying to get our drugs.
Hope that answers your questions.