Posted by: kevinfortruth | February 15, 2012

Need your feedback on Medical Care – who does what?

Years ago when I was living in San Antonio, Texas, my health care professionals would write prescriptions that I would take to get filled.   At times, the doctor’s office would call in the prescription(s) to the pharmacy, which was a nice additional service that would expedite the prescription getting filled quicker.

If memory serves me well, I never had a pharmacist tell me that a given prescription was not covered by the  health plan I was under at the time.

Maybe I was spoiled back then, but I do not think that was the case.

The issue I am concerned with has nothing to do with a brand name prescription versus its’ generic equivalent – my issue has to do with who determines what pills are covered by a given plan.

Several weeks ago I went to my doctor and he prescribed a prescription that I took to my local grocer/pharmacy.  I normally get my prescriptions via mail order but when I get a new prescription, I get the first dosage filled locally and if I need refills, I get them via mail order.

For the purpose of this blog, neither the given prescription – nor the medical diagnosis is the issue.

Our government has recently, in the past year or so, implemented a law that appears to have improved medical record keeping and designed standard requirements for maintaining health records so as to allow physicians and medical facilities immediate access to patient information in a way to assist the doctor and other health care professionals in providing the best possible care to the his/her patient.

What I do remember about my medical care back in Texas is this:

1.       The nurse and/or doctor would ask me if there was anything I was allergic to before the doctor would actually write the prescription.

2.     When paying my co-pay at the end of my visit, the nurse or medical assistant would hand me the prescription that I would take to my pharmacy to get filled.

3.     If memory serves me right, there was only one time when the pharmacy did not have the drug by name or the drug in the required dosage – at which time the pharmacist gave me the smaller quantity and told me to come back the next day to get the remaining pills.

After my recent visit to my doctor, he wrote a prescription that I took to my local pharmacist who told me that my health plan did not approve the drug that was prescribed.  The issue was not brand name versus generic, it was that my plan chose to not list the drug in question on its formulary – therefore the drug could not be dispensed to me.

So, the pharmacist offered to call my medical clinic to see if the doctor wanted to prescribe another drug for me.

When I saw my doctor the next day, he suggested that I contact my health plan to see what drugs they had in their formulary.  I was perplexed that he would ask me to do this – not that I was opposed to doing it, considering that it would be in my best interests to do so – I just thought that because of all the sensitivity of health care data for patients, I would think the safest bet was for the doctor or his staff to do this function.

How about you?  Does your doctor’s office take care of determining what drug to provide you based on your health care plan?  Do they do all the background work necessary to find out what CAN be prescribed for you?

I might be oversimplifying things but one would think that health care facilities should have automated access to all the health plans to review formularies before prescribing prescriptions to those covered by health plans.

Please take part in the two poll questions below and if you have a personal experience that you would like to share on this blog, feel free to do so.

Please do not give specifics that might not be in your best interest to share.  Talk in generalities and I am sure everyone will understand your particular situation.

My gut tells me that my health care facility is choosing to minimize their involvement to save time and money by shifting the burden to the patient.

Considering that most times we go to the doctor we have no idea what the actual problem or solution is, and as a result, we have no idea of what our plans cover – and if we have to leave the office to return home to call our health plan administrator to determine what meds they will approve, it will warrant an extra visit to the doctor before the proper prescription can be prescribed.

Again, please participate in the two polls and by all means, leave a comment if you have time.  Thanks.





  1. Hey Kevin,
    Very interesting topic today I find that my dr. knows which drugs are covered under my health plan. I am sorry trhat you have to go thourgh this crap to get your meds.

    • Hi Amiee; I believe all doctors are capable of determining what drugs are covered on each patient’s plan – the problem is if they want to take the time to do it right the first time so that when a patient takes the prescription to the pharmacy it is not turned down because the plan does not cover that particular prescription.

      The doctor could easily have his nurse or administrative person check a plan to see what drugs are available on that patients plan. Some seem to care less if they get it right or wrong. IMHO.

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