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Pharmacy Issues
#1
I have an Rx drug plan from a PBM in the US. Last fall they went behind my back and contacted my doctor without consent. They got him to change an Rx strength and dose regimen. Years of experience have shown I cannot tolerate them in a single dose, I require BID dosing. I wrote to their Chief Privacy Officer and explicitly told them I require them to contact me first before my doctor to request any change in how an Rx is written. They just ignored that; and did it again. I'm not sure if that's a HIPPA violation; but it's definitely an interference with the patient-physician mutual consent practice of medicine. It's partly my doc's fault for agreeing to the change. I'll correct that issue by having him write "fill as written" on all scripts.
My real "beef" is with the CPO of the PBM who defied my order by contacting my physician.

What are my legal remedies?
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#2
(12-13-2013, 05:03 PM)justMongo Wrote: I have an Rx drug plan from a PBM in the US. Last fall they went behind my back and contacted my doctor without consent. They got him to change an Rx strength and dose regimen. Years of experience have shown I cannot tolerate them in a single dose, I require BID dosing. I wrote to their Chief Privacy Officer and explicitly told them I require them to contact me first before my doctor to request any change in how an Rx is written. They just ignored that; and did it again. I'm not sure if that's a HIPPA violation; but it's definitely an interference with the patient-physician mutual consent practice of medicine. It's partly my doc's fault for agreeing to the change. I'll correct that issue by having him write "fill as written" on all scripts.
My real "beef" is with the CPO of the PBM who defied my order by contacting my physician.

What are my legal remedies?

I don't know what PBM is or maybe I just don't know it by the abbreviation? There might be an organization that you can file complaints with, an organization that governs this Rx provider. And I don't understand why an Rx provider would think they have the right to dictate to a doctor how the Rx is distributed and why the doctor would let an Rx provider dictate the same to him or her. I hope I understand your post correctly. You could always talk to an attorney about this but not sure that is cost effective.
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#3
(12-13-2013, 05:03 PM)justMongo Wrote: It's partly my doc's fault for agreeing to the change. I'll correct that issue by having him write "fill as written" on all scripts.
They can contact the doctor and ask whatever but the doctor first and foremost duty of care is toward you
He should know better than agreeing to their demand
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#4
(12-13-2013, 05:35 PM)me50 Wrote: I don't know what PBM is or maybe I just don't know it by the abbreviation? There might be an organization that you can file complaints with, an organization that governs this Rx provider. And I don't understand why an Rx provider would think they have the right to dictate to a doctor how the Rx is distributed and why the doctor would let an Rx provider dictate the same to him or her. I hope I understand your post correctly. You could always talk to an attorney about this but not sure that is cost effective.

PBM - Pharmacy Benefit Manager.
An example would be express-scripts; although they are not the PBM in question. Many healthcare plans carve out the Rx benefit and sub contract to a PBM.
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#5
(12-13-2013, 05:49 PM)zonk Wrote:
(12-13-2013, 05:03 PM)justMongo Wrote: It's partly my doc's fault for agreeing to the change. I'll correct that issue by having him write "fill as written" on all scripts.
They can contact the doctor and ask whatever but the doctor first and foremost duty of care is toward you
He should know better than agreeing to their demand

Yes, I agree. He's a good doc; and I do not wish to alienate him.
I'll explain the issue to him.

Can they really contact my doc and ask anything -- after I have informed their Privacy Officer that I forbid them to contact my doc?
That's the issue I'll really fuming over. I'm considering filing a HIPPA complaint with HHS.

I'm also seeking an attorney to clean the PBM's clock.
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#6
Actually, you probably don't have a case. They do this all the time.

I had a medication I was taking for a long time. The plan changed their formulary and that medication was moved to their "must have prior approval" and was on a "step down" or something like that. Meaning I was to be weaned off of it and put on something else. They contacted the pharmacy and told them to have the doc change the script and put me on a different medication.

Luckily, my pharmacy is a small, non-chain, they knew my drug history, and they said no. They presented my medication history, that I had already tried the medication they wanted to switch me to, and that to "step me down" would be a waste of time and money.

All of this was settled without me knowing. The pharmacy conferred with my doctor who agreed with them. They wrote the appropriate letters and everything was done. The next time I went in for a refill, the pharmacy said "Oh, yeah, by the way..."

This has happened several times now, with different prescription plans. In none of these was I ever consulted. And I wouldn't have been unless the change was necessary. I wouldn't have had any choice but to comply and then to demonstrate that the change was or was not working.
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#7
Well, I still have leverage. Since my Rx plan is partially paid for by a stipend from a major US Government contractor. And, since they chose to deal with criminals, thieves and liars whose business model is to collect premiums and not deliver service -- I can expose every government contract where they used falsified financial data to underbid the contract in a public forum.
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