Medications

Controlled substances are medications that are regulated by the government due to their potential for abuse or addiction. Key characteristics include:

• High potential for abuse or addiction
• Require special prescription protocols and paperwork
• Subject to strict regulations on prescribing, dispensing, and refills
• Examples include opioids, stimulants, and certain anxiety medications.

Non-controlled medications are pharmaceutical preparations that do not have a significant potential for abuse or addiction. These include:

• Most prescriptions for infections or chronic conditions
• Over-the-counter medications
• Common examples: blood pressure medications, cholesterol medications, insulin, asthma inhalers, and antibiotics

If your medication is lost or stolen, there are several steps you should take and potential consequences to be aware of:

1. Report the incident immediately to your healthcare provider and pharmacy.
2. File a police report if the medication was stolen. This is often required, especially for controlled substances.
3. Be prepared for potential consequences:
   • You may be required to go without medication for a period of time, depending on your current prescription schedule.
   • Your healthcare provider will require office visit to discuss situation.
   • You may need to pay out-of-pocket for replacement medication, as insurance typically won’t cover early refills.

Proactive Measures

1. Call ahead: Contact your pharmacy in advance to confirm that your prescription is ready for pick-up. This can save you time and prevent unnecessary trips.
2. Check insurance coverage: Verify that your medication is still covered by your insurance plan. If not, you may need to discuss alternatives with your healthcare provider.

Addressing Specific Problems:

Prescription not ready: If your prescription isn’t ready when you arrive, ask the pharmacist for an estimated completion time. You can either wait or return later.

Medication out of stock: Ask the pharmacist to check if another store in their chain has the medication. Alternatively, contact your doctor to have the prescription sent to a different pharmacy where the medication is available.
No refills remaining: Contact your healthcare provider immediately to request a refill. In some cases, pharmacists may provide a 72-hour emergency supply of certain medications

Lost or stolen medication: Report the incident to your healthcare provider and pharmacy. For controlled substances, you may need to file a police report

When to Seek Further Assistance

1. Contact the pharmacy: If you encounter any issues, start by discussing them directly with the pharmacy staff.
2. Reach out to your care team: If the problem persists, inform your healthcare provider. They can help resolve issues or provide alternative solutions.
3. Consider switching pharmacies: If you consistently experience delays or problems, you might want to transfer your prescriptions to a different pharmacy. Ask friends for recommendations or check with your insurance company for in-network options.

Prior Authorization is a process required by some insurance plans for certain medications. It involves:

• Extra approval needed for specific medications
• Your healthcare provider submitting additional information to justify the prescription
• Insurance review of the information to determine coverage

Obtaining Prior Authorization

What We Need From You

• Details from your insurance card: Member ID, RxBIN, PCN, and RxGroup
• If you have a separate prescription card, send pictures of both sides via chat
• Alternatively, contact your insurance directly for this information

What to Expect

• PAs are processed in order, with urgent requests prioritized
• Process typically begins when pharmacy attempts to fill prescription
• We aim to process within 2 business days
• Insurance decision may take 3-5 business days
• Check status by contacting your insurance company

Expedited Prior Authorization

• Available if waiting could seriously jeopardize your health
• Consider paying out-of-pocket and seeking reimbursement later if approved

After Approval

• Inform your pharmacy
• Check for any copays
• Note: Changes in dosage or quantity may require new authorization

Understanding Insurance Plan Formulary

• A list of medications covered by your plan
• Designed for cost-effective treatment
• May not include all medications
• Contact insurance for specific formulary information

Dealing with Prior Authorization Denials

If denied, you can:

1. Request alternatives from your insurance and consult your provider
2. Pay out-of-pocket (consider manufacturer discounts or GoodRx)
3. Submit an appeal following instructions in the denial letter

Plan Exclusions and Restrictions

• Plan Exclusion: Some medications are never covered
• Step Therapy: Requires trying cost-effective alternatives first
• Quantity Limits: Restrictions on amount covered in a given period
• Clinical Criteria: Coverage based on medical necessity and FDA guidelines

Sometimes, circumstances beyond our control necessitate moving your prescriptions to a different pharmacy. This process is known as medication re-routing. It involves transferring your prescription from the initially selected pharmacy to a new one.

Non-Controlled Prescriptions Process:

Simple and quick, typically completed within a day

• No intervention required from your care team
• Can be transferred between any pharmacies, regardless of chain affiliation

When to Request

• No time restrictions
• Can be initiated as soon as you notice delays or issues at the original pharmacy

How to Request

1. Contact the new pharmacy where you want your prescription moved
2. Provide them with your prescription details and current pharmacy information
3. The new pharmacy will handle the transfer process

Controlled Substance Prescriptions Process:

• More complex due to regulations
• Involves cancelling the original prescription, clinical review, database verification, and re-prescribing
• Additional checks required by the pharmacist
• Can take several days to complete
• Only possible within the state where both patient and provider are located

When to Request

• Cannot be re-routed once the medication has been dispensed

How to Request

1. Send a message via online patient portal or can call office staff
2. Follow prompts to provide necessary information
3. Your request will be reviewed as soon as possible