As technicians, we wear many hats around the office, and a big part of our job happens behind the scenes, after the patients are gone. From restocking supplies to doing inventory to answering voicemails, the list of administrative duties seems to be never-ending.
For many technicians, one of the least enjoyable—but most critical—aspects of the day-to-day is dealing with pharmacies to fulfill prescriptions. As patient advocates, we want to ensure our patients receive the precise prescribed treatment in a timely manner.
Unfortunately, insurance companies and pharmacies seem to be set on making this task as time-consuming and difficult as possible. The innumerable hoops to jump through and red tape to navigate can quickly lead to frustration. However, there are a few things we can do to set ourselves up for success.
eRx is a gamechanger
Gone are the days of prescription pads and illegible handwriting.
E-prescribing (eRx) has changed the game, and offers a range of benefits for both patients and practices, including:1
- Increasing operations efficiency for both practices and pharmacies
- Reduces the risk of incorrect transcribing
- Decreases the chance of incomplete information with required fields
- Expands patient safety and privacy
- Provides a database containing historical patient prescribing information
- Offers alerts
In addition, it allows us to instantly transmit prescriptions to the patient’s pharmacy and monitor their status. It is also one of the best tools we can use to get our prescriptions right from the get-go and save ourselves time dealing with callbacks from the pharmacy on the back end.
Here are some things to consider to make the best use of our eRx software:
1. Build a list of “favorites”
Every doctor is likely to have their own list of frequently prescribed drugs. As a technician, keeping a list of each doctor's favorites, along with the alternatives, specific dosages, directions, and special instructions (when applicable) can prevent technicians from wasting precious time, on the back end, facilitating pharmacy callbacks.
2. Substantiate substitutions
Make sure to check the box to indicate when a generic substitution is not authorized for any of the medications on the doctors’ “favorites” list.
Depending on your state, it may be labeled:
- "Do not substitute" (DNS)
- “Dispense as written” (DAW)
- “Brand medically necessary” (BMN)
Checking the appropriate box will ensure the patient receives the intended treatment and not an unauthorized substitution. In addition, this simple step reduces the number of callbacks and faxes we receive, both from pharmacies and confused patients.
3. Be aware of quantity limits
Another common roadblock is the prescribed quantity for a specific drug. Many managed care plans have different quantity limits for different drugs. To save our patients time and money, it is tempting to prescribe a 90-day supply; however, the Rx can be rejected by the pharmacy if the quantity prescribed exceeds the limit covered by the patient’s insurance plan.
To avoid this, include a note in the “comments to pharmacist” section that instructs the pharmacy to dispense the maximum allowed quantity by the patient’s plan. This is particularly helpful for chronic topical therapeutics, such as medications for glaucoma or dry eye disease.
Pro Tip: Quantity limit rejections do not require a callback to the office; the patient can simply override it by asking for the maximum quantity allowed. Many patients aren’t aware of this and tend to leave empty-handed when presented with the challenge. Be sure to educate your patients appropriately.
4. Utilize automated prior authorizations
If the patient’s information has been correctly entered in the system, most electronic medical records (EMRs) and eRx platforms offer the ability to electronically initiate prior authorizations or, at least, to notify the user when a medication being prescribed requires a prior authorization.
This allows us to be proactive and initiate the prior authorization or substitute for a covered medication when time is of the essence. Unfortunately, some government-sponsored plans, like Medicare and Medicaid, do not support electronic prior authorizations yet and still rely on forms being completed by hand and transmitted via fax.2
For more information on how to tackle prior authorizations, check out the article Prior Authorization: Getting It Right the First Time.
Avoid sending faxes when possible
While the fax machine still plays a very important role in the day-to-day business activities of our office, we should not be relying on it when it comes to dealing with pharmacies. Chasing down your doctor during clinic for an autograph is not efficient and disrupts workflow.
Additionally, faxes are often confusing. Every request for refill or clarification can be easily and effectively communicated through eRx software. This not only saves valuable time but ensures patients are getting the prescribed treatment faster and more accurately. Also, do not underestimate the financial and environmental implications of sending and receiving thousands of faxes every month.
At most practices, requests for substitutions are not uncommon; these can come from both the pharmacy or the patient’s insurance plan. In some cases, this is to inform us of a more affordable alternative that is available under the patient’s specific plan. These require no action and can swiftly be thrown in the shredder pile, unless a cheaper alternative is requested by the patient and, more importantly, approved by the physician.
While some tasks—such as referrals, medical records requests, surgical predeterminations, and certain prior authorizations for government-sponsored plans—still depend on fax transmissions, pharmacy communications can, for the most part, be kept in the digital world.
How to handle prescription rejections
Sometimes, despite our best efforts, we receive notification that a prescription was rejected or the patient wasn’t able to get it filled. Identifying the specific reason behind the rejection can help us correct the issue.
The easiest way to identify where the error lies is by finding out the “Rejection Code” from the pharmacy. These are usually included in any fax notification about the rejection; if not, make a quick call to the pharmacy to procure the proper code.
Rejection codes were established by The National Council for Prescription Drug Programs (NCPDP) as a standardized system to identify rejection reasons. These codes are largely the same across different pharmacies and payers nationwide.
Some common rejection codes include:
- 65: Patient not covered
- 70: Product or service not covered
- 75: Prior authorization required
- 76: Plan limitation exceeded (quantity limit)
- 79: Refill too soon
Other error codes refer to syntax errors on the actual prescription and can include missing components, such as dosage, quantity, or drug strength. With the use of eRx, these causes for error codes are becoming less common.
If the pharmacy is unable to provide a rejection code, it could mean the patient’s insurance wasn’t properly run. If the patient has secondary insurance that wasn’t provided, we can request the pharmacist to run it again. If the callback is from the patient regarding cost, ensure their benefits have been accurately verified with the pharmacy and all savings programs and coupons have been applied (when possible).
Empower patients with information to navigate pharmacy visits
Preparing the patient for their interaction with the pharmacy can go a long way to ensuring they acquire the right medications in the right quantities the first time around.3 Educate patients on what to expect when they go to the pharmacy.
If your eRx software provides the information below, make certain patients understand:3
- Which medication/s they should receive
- How they are supposed to use it
- How much they can expect to pay
Also, provide the patient with any handouts, coupons, or savings program materials available for specific medications for those who qualify and explain how to redeem each.
Final thoughts
As a technician, dealing with pharmacies is one of my least favorite tasks, but it is necessary to ensure our patients receive the recommended treatment in the timeliest manner.
By staying abreast of the latest requirements, understanding the capabilities and limitations of e-prescribing, and knowing the reasons for rejection, we can increase our chances for first-time success and decrease the frustration and administrative burden.
