prescription process- the path from the Dr to the Pharmacy

[me2]

I hope someone knows how this works. My mind is in a fog but even with that I think the problem is not me but some system I don't understand.

Sixteen days ago my Dr wrote a prescription for me to receive Rituxan. Apparently there is some office within the Medical Center where he works that the prescription gets sent to before it is gets submitted to the insurance company.

He wrote the prescription but the insurance company has not received it. This of course means that I cannot begin treatment. This means that for more than two weeks I have been getting worse , without treatment. I have been through this process before with the same Doc, same medication , and the same insurance company. In the past it took two days and I was able to start treatment.

I have been phoning the doctors office several times during the past week and they tell me things are probably slowed down due to the holidays. I cannot believe they do not have a process to get a prescription delivered to the insurance company for over two weeks 'because of the holidays'.

Does anyone know where a prescription goes before it leaves a clinic? I want to be ready to work on this Monday when I can make some calls and find out what is going on and I would call the Medical Center office first that is sitting on this if I can figure out where to start.

[Masha]

I know when we are in pain everything is magnified 100%. While reading your dilemma, the first thing I thought of was “the holidays”. Sad to say but that seems to be the world we live in today. Your orders could be just sitting on someone’s desk.
Maybe your first phone call could be back to your doctors office to ask them the direct phone number or extension in the Medical office of where your paperwork was sent. Then call them and tell them the pain you are in and ask what could be done to fast track it. If you are getting nowhere then a personal visit may be called for. This is usually where you show up with cookies or candy and beg on bended knee.
You also could take the route of going directly to the supervisor of the person who has this sitting on their desk. I wouldn’t be surprised if the person responsible for this is on vacation.
Really, your story just burns me up. When I worked (and yes I will be 70 in a few weeks) clients were never treated this way.
The buck stops somewhere. Go after it, and as a wise man once told me ‘You will catch more bees with honey.’
Tell us what happens.
Masha

[me2]

Those are some good ideas. Thanks for taking the time. I will let you know how it works out.

[drz]

I have often experienced the "black hole" phenomena when orders and medical info is sent from one clinic to another. It is so routine for me that now I get a paper copy of any prescriptions so I can forward it on myself or give it to another facility in person. I often ask doctors to resend things. Many times orders or prescriptions have to be sent several times before I get any action on them from some vendors for my diabetic supplies. I have found it often helps things if I can get a hard paper copy of any orders that are sent since sometimes they are needed to get the order filled.

One time my local clinic could not find an order for a lab order that another clinic doctor had sent them even after it was sent three times. I then asked a local doctor to duplicate the order and the local lab clinic still could not find the order. A week later they found several orders for the same tests.

My local clinic has never received any info from the clinic where I see the doctor who manages my GPA even though that clinic state such info has been sent many times. In these cases I have no idea where the problem lies, the sending clinic or the receiving clinic or in the electronic transmittal system since we know that computer systems are not perfect. I can print out the lab results but not the notes and give them to another clinic and asked them to input them manually but then the doctors at that clinic seldom know how to access or find such info so I usually bring the paper copies along to give them in person so they have my latest info.

In a rural area it is necessary for me to use several different clinics to find appropriate specialists for my health care team and trying to coordinate the info between them is a challenge. When you add in the insurance companies and suppliers for medical supplies coordinating things is very time consuming and nearly a full time job. Some of my clinics seem to share their electronic records or use the same system where they can access each others info but my local one does not share with any others.

I don't know how any one trying to maintain a job and family manages to do it. I am lucky I am retired and can usually find the time to make all the needed phone calls and emails and contacts on their web sites to eventually get the things done needed to manage my health care. Getting diabetic supplies is the hardest and most time consuming thing to do once you are on Medicare in the USA.

[me2]

Wow DRZ , you have truly been in the black hole.

I had to wait another day and I'm not sure things are still straightened out yet. Of course the TELL me it is but I was also told that two weeks ago. Masha I agree with you totally about doing things in person but this facility is a long , hard full days travel away from me and honestly I just feel too sick to do it. Many days I don't feel good enough to even make calls until after noon.

I have been getting different 'reasons' from different offices. I don't know what to believe. All I can do is keep trying and hope for the best. I appreciate you all talking to me about it and sharing experience and ideas.

One surprising bit in this is that the insurance company has been of more help than the doctors office. One insurance person today put me on hold and called the doctors office on my behalf. Later in the day I actually got a call from the doctors office saying they were working on it.

[John S]

Patti, in Dr. VillaForte’s office has been wonderful in making sure that everything runs smoothly for me. I get the Rituximab infusion every 6 months. She sets up my appointment three months in advance and coordinates it so that I can see the Dr. first thing in the morning then go to the “chair”.
Patti also makes sure that Medicare and my supplemental carrier have given advance approval.
Cleveland Clinic is the best.

[Pete]

John S

I must add a hearty Amen!!

Happy New Year!!!

[Masha]

I really hear you on being too sick to move. I have been lucky enough to have a retired husband who has made in person trips on my behalf. All you can do is keep plugging away. Let’s hope 2020 is better.
Masha

[Alysia]

I really hear you on being too sick to move.
Masha

Like I told my dr.: "I must be healthy in order to be sick".

[vdub]

Interesting that no one mentioned the cost of rtx or, at least, I didn't see it mentioned. The reason I mention it is because it is semi-expensive, so I can guarantee you that it is going to get the first, second, and third degree from your insurance company before its approved and, yes, the holidays slow down everything. Its probably moving through all the wickets, but its a slow slog even during the best of times.

My experience is that you have to be your own best advocate. Masha is right (believe it was Masha) that doing things in person is always best, but, short of that, keep good records of who you talk to, when you talked, and what they said. Eventually, you'll get to the bottom line. My guess is that it got to the insurance company, they declined the rx and wanted more justification, which took more time on your end and then it was sent back through. But, that's just a guess. Good luck!!

[me2]

First, I want to thank you all who have responded with ideas and encouragement. After twenty years of chemotherapy, illness , pain and prednisone (yes, for the ENTIRE time I have had all of this going on .EVERY day. ) I have no friends left. People want to talk about the normal and positive things in life (as do I myself) and get 'friend fatigue' by someone who doesn't just get better and move on with things. I very much try and move on with things but I'm dragging this lead weight of all these things.

So, an update on the prescription written several weeks ago for a Rituxan infusion. A new twist has emerged that I have never encountered before. I talked with the insurance company and they have denied the request for 750 mg Rituxan infusion. They say they would APPROVE a 500 mg infusion. I asked the VERY helpful insurance rep "This is new to me. Does this mean the insurance company has a doctor that looks at the request (and my situation) and is disagreeing with my doctor just on the dosage?"

She says "Yes, there is a panel of doctors who look over the request and they are suggesting the lower dosage. "

I called my doctor and talked to his very pleasant and helpful office person and she said that they had also received this information and it might be a week before my doctor can look it over and I will hear back. I told her "I have already been waiting several weeks to begin this treatment" . She said she knew that but it still might take that long to go through their process.

I told her that I trust my doctor completely to make this decision for me but that I myself would be ok with the lower dose- but only if he thinks it is ok. Ironically, I MYSELF was hoping to do a lower dose. My antibody count is below the normal range. I think I would do well with a low dose- but I'm aware that I don't have the extensive experience that my doctor has. I actually, truly, trust him to be making what he thinks is the best decision. If he and I could talk I know he would explain his ideas behind the dose choice.

So, I am taking all of this as PROGRESS. I am actually approved to get the Rituxan and it is only left up to working out the dose. Some day, I hope to come back and report what I have learned about how Rituxan doses are decided as I literally know nothing about that is done. I am curious as to what an absolute minimum dose is and what the logic is behind it.

Thanks again for those of you giving my your time with encouragement and ideas.

Oh, and VDub . I understand what you are saying about the cost. If they are talking about it all they have not mentioned it to me. It truly seems like they are just considering what is the best care for me- which is a bit surprising to me too. Also surprising is that the insurance company has been so helpful and kind. One person put me on hold recently and called the Dr office on my behalf. Soon after that I heard from the doctor's office. She wasn't just 'doing her job' she actually cared that I was 'getting the run around' and wanted to help me. A reminder to me how important just one person can be.

[Masha]

You are so right about people fading away. When I was diagnosed my husband reminded me of when his brother was diagnosed with a brain tumor. He was a fun loving, kind and popular person. By the time he passed away (2 years) almost eveyone had faded away. But what is most hurtful is that before I was sick, I was attentive to so many peoples ailments. I cooked and delivered many meals, sent cards, visited. Not one person has done it for me. My neighbor tells me at club meetings they ask about me. One person actually said ‘tell Masha we love her.’ Thank goodness for the wonderful people at this site. We have walked a mile in each other shoes.
I sure hope hey hurry up with your Rituxin. I have to wonder if any of the doctors on the board deciding your case uwould feel if they had ever gone through the pain we go through.
Masha

[me2]

Thanks Masha. I have wondered the same things.

[vdub]

At least you found something out. That's great!

[drz]

It is hard to read about that things that impinge upon us Weggies getting good care and not have a strong visceral reaction. It is hard for me not to be skeptical about the motives of insurance company doctors reviewing your care. I have known some very bad doctors who went to work at insurance companies just to deny coverage for the patients in order to save the company money. The job was find any excuse they could to deny a claim.

But I too have had some very good experiences with reps from my insurance company who have spent hours on the phone with me and calling vendors to help me get the supplies I need to help manage my diabetes. They have gone the extra mile and seem to radiate genuine concern for my welfare. It is a great feeling when you have those encounters since getting good health care today is often a crap shoot with a lot of frustration at times and great feelings of relief and joy when you get really good care and help, especially when it literally saves your life.

It is nice we have this forum to help support each other even if some times we just pool our ignorance and frustration but often we get some great pearls of wisdom and sage advice.

[me2]

I DO appreciate your responses and your concern.

[me2]

Update - 33 days after being prescribed Rituxan I now have an appointment to get the infusion- and a notebook of notes almost an inch thick. I need to just de-stress and get ready for the 5 hour drive to the clinic tomorrow. Thanks for everyones input and encouragement.

[drz]

Update - 33 days after being prescribed Rituxan I now have an appointment to get the infusion- and a notebook of notes almost an inch thick. I need to just de-stress and get ready for the 5 hour drive to the clinic tomorrow. Thanks for everyones input and encouragement.

Hope it goes well for you!