Shields "Care Corner" Blog

Conquering Insurance and Chain-Store Red Tape for a Patient in Urgent Need

From the pharmacy team: We have a patient in our hospital clinic who is prohibited by her insurance from filling prescriptions with the hospital specialty pharmacy. We call that “insurance lockout.” So the patient has to fill her prescriptions with a large Wall Street-owned pharmacy chain. Since before we started the patient’s prior authorization (PA) paperwork and discovered she could not fill with the hospital pharmacy, she had several issues surface with medications where the hospital pharmacy team has provided assistance. We help every patient, not just those that fill with us and we’re proud of that. In the case of this patient, we even provided help with medications that were not prescribed by a physician in our clinic.


As a pharmacy liaison, I speak with this patient each time she comes into the clinic. For some reason she is always misinformed by the chain-store specialty pharmacy about her orders and deliveries. Today I received a call from her because she had yet another issue with her medication, this time with delivery, and needed urgent help.


The chain-store pharmacy promised delivery of her Humira® medication the day before, but she did not receive it. After she reached out to find out why, she was given information she didn’t understand. So she called me to see if I could assist. I spoke with the chain-store pharmacy, with the patient also on the phone. It turned out that all that was needed was a new dosage level for her prescription but the pharmacy held back the order because of the issue, leaving the patient without any medication.


After the call I reached out to the physician and had him send a new prescription for Humira CF. The entire issue took about 2 hours to resolve. The patient was so grateful for our team’s assistance, in this moment and many times before, she informed her clinic nurse. In the patient’s Electronic Medical Record there is now a note saying, "The patient spoke to Kelli (hospital pharmacy Liaison) about her medication delivery problem and was grateful for her assistance in resolving the issue.  The patient feels the issue has been resolved and would like to say how wonderful Kelli and the specialty pharmacy team have been with her care." 

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