No medication without insurance...

[Dann]

Jurisdiction

New Jersey

I'm not sure if this is the right place to ask this question, but I'm not sure where else to ask it.

I tried filling a prescription at CVS for HYDROCODONE a few weeks ago. CVS told me that it required prior authorization from my prescription insurance company, which happens to be CVS Caremark. I said that rather than wait, since it would likely take many days and I needed the medication asap, I would pay out of pocket. They said that they would not fill it without prior authorization from insurance.

Is this legal? What if I didn't have insurance? Would I not be able to fill this medication? When I called CVS Caremark, they said it's done to combat the opioid epidemic. But why is it their responsibility to do this? Can CVS and CVS Caremark prevent me from getting medication that my doctor prescribed me because it doesn't have insurance approval? FYI, it took approximately 5 days to get prior authorization approved, then CVS said they had to order the medication. So I didn't get it filled for 8/9 days from when the prescription was ordered by my doctor.

 

[Zigner]

Your question is moot as the problem has already been solved.
If you don't like the way CVS handled this, use a different pharmacy.

 

[Dann]

Your question is moot as the problem has already been solved.
If you don't like the way CVS handled this, use a different pharmacy.

Maybe my question wasn't clear. Is this legal? What if I didn't have insurance? Would I not be able to fill this medication? Additionally, is this how it is handled at all pharmacies? Or is this just CVS?

 

[Zigner]

Maybe my question wasn't clear. Is this legal? What if I didn't have insurance? Would I not be able to fill this medication?

All of these questions are moot, as your problem has been solved.

Additionally, is this how it is handled at all pharmacies? Or is this just CVS?

Not a legal question.

 

[Dann]

All of these questions are moot, as your problem has been solved.
Not a legal question.

My first question, "Is this legal?" is a legal question. And my additional questions were in response to your reply, "If you don't like the way CVS handled this, use a different pharmacy."

 

[Zigner]

My first question, "Is this legal?" is a legal question. And my additional questions were in response to your reply, "If you don't like the way CVS handled this, use a different pharmacy."

Yes, it's legal.

 

[adjusterjack]

Maybe my question wasn't clear. Is this legal? What if I didn't have insurance? Would I not be able to fill this medication? Additionally, is this how it is handled at all pharmacies? Or is this just CVS?

My guess it that CVS has a contractual arrangement with CVS Caremark that obliges the CVS pharmacist to follow certain rules. So, yes, it's legal.

If you didn't have CVS Caremark but had other insurance to which CVS was under contract, the same thing might have happened.

If you had no insurance at all, CVS pharmacy would have no contractual obligation for pre-authorization but would also have no legal obligation to fill your prescription and could legally choose not to as long as the refusal was not due to illegal discrimination.

 

[welkin]

You can always file a complaint with the NJ Board of Pharmacy.
https://www.njconsumeraffairs.gov/ComplaintsForms/Board-of-Pharmacy-Complaint-Form.pdf

If you are covered under the ADA, you can also file a complaint.

 

[zddoodah]

Is this legal?

Yes. A merchant has nearly unfettered discretion to dictate the terms under which it chooses to sell a product. Of course, pharmaceutical sales is a heavily regulated area of commerce, but nothing in those regulations prohibits what you described.

What if I didn't have insurance?

You did have insurance, so this is as meaningless a question as "what if I had a prehensile tail and only one eye?"

But why is it their responsibility to do this?

It isn't. However, it is the merchant's prerogative to take steps to "combat" the "epidemic," and you don't get to second guess that decision.

is this how it is handled at all pharmacies?

This isn't a legal question, and I doubt anyone here knows.

 

[Zigner]

You can always file a complaint with the NJ Board of Pharmacy.
https://www.njconsumeraffairs.gov/ComplaintsForms/Board-of-Pharmacy-Complaint-Form.pdf

If you are covered under the ADA, you can also file a complaint.

I don't disagree that a complaint can be filed, but I don't see the reason for filing a complaint in the first place. The pharmacy didn't discriminate against the OP in any way.

 

[Redemptionman]

Yeah, this is very legal. Most states now have investigative branches which try to bust (if you will) doctors who over prescribe listed narcotics. Whether fair, right or wrong it is what it is. Some pharmacy's will not even fill certain listed medications regardless of who wrote them.

 

[cbg]

Maybe my question wasn't clear. Is this legal? What if I didn't have insurance? Would I not be able to fill this medication? Additionally, is this how it is handled at all pharmacies? Or is this just CVS?

40 years experience with group medical insurance here:

First of all; Is this legal? Yes. Your insurance policy is a contract. It says they will pay for certain items when certain conditions are followed. This is one of the conditions.

What if I didn't have insurance? Then there wouldn't be a contract and you wouldn't be bound by any contractual limitations. But you do have insurance and thus you are.

Would I not be able to fill this medication? You would be able to fill the prescription, and you would be able to pay every penny of it by yourself with no reimbursement

Additionally, is this how it is handled at all pharmacies? Yup. If the insurance policy says they need a pre-auth, then every pharmacy had better get a pre-auth.

Or is this just CVS? No, it's not just CVS. And CVS is only following the rules set down by your insurance carrier. If they didn't, they'd be the ones on the hook for the cost.

 

[Zigner]

40 years experience with group medical insurance here:

First of all; Is this legal? Yes. Your insurance policy is a contract. It says they will pay for certain items when certain conditions are followed. This is one of the conditions.

What if I didn't have insurance? Then there wouldn't be a contract and you wouldn't be bound by any contractual limitations. But you do have insurance and thus you are.

Would I not be able to fill this medication? You would be able to fill the prescription, and you would be able to pay every penny of it by yourself with no reimbursement

Additionally, is this how it is handled at all pharmacies? Yup. If the insurance policy says they need a pre-auth, then every pharmacy had better get a pre-auth.

Or is this just CVS? No, it's not just CVS. And CVS is only following the rules set down by your insurance carrier. If they didn't, they'd be the ones on the hook for the cost.

The OP wanted to pay in cash instead of submitting it through their insurance, and that is something they can do if the pharmacy allows it. The problem is that the pharmacy doesn't have to allow it.

 

[cbg]

I understood that he wanted to pay for the medication up front and then be reimbursed by the insurance, in which case the insurance carrier makes the rules. But if he wanted to by-pass the insurance altogether, then I agree with you; the pharmacy can allow it but doesn't have to.

 

[Zigner]

I understood that he wanted to pay for the medication up front and then be reimbursed by the insurance, in which case the insurance carrier makes the rules. But if he wanted to by-pass the insurance altogether, then I agree with you; the pharmacy can allow it but doesn't have to.

I read it to be that he just wanted to pay for it outright. I agree that getting reimbursed would be problematic, at best.

 

[welkin]

I don't disagree that a complaint can be filed, but I don't see the reason for filing a complaint in the first place. The pharmacy didn't discriminate against the OP in any way.

Since what happened is legal and OP feels he wants some satisfaction, I thought I would give him a way to vent. You never know what the Board might do or tell him.

 

[Zigner]

Since what happened is legal and OP feels he wants some satisfaction, I thought I would give him a way to vent. You never know what the Board might do or tell him.

I see where you're coming from. I guess I'm more of the opinion that one shouldn't waste the time of others when one is clearly wrong.

 

[Tax Counsel]

Maybe my question wasn't clear. Is this legal? What if I didn't have insurance? Would I not be able to fill this medication? Additionally, is this how it is handled at all pharmacies? Or is this just CVS?

CVS is in the middle of making some significant changes to how it operates and the way it will determine the prices of drugs sold. The position the pharmacy took is legal, though it caused you extra days of pain because of it. You have my sympathy on that. I've suffered decades of pain and when it spikes and I need stronger pain medication any delays in getting leaves me in great pain. But even as a lawyer there's nothing I can do to speed up the process.

With opioid drugs in particular all the major pharmacy chains have some policy in place to help curb the abuse of these drugs. They have to do that because the federal government has a rule forcing them to act to prevent abuse and if they don't they can lose their DEA license to fill prescriptions for controlled substances. Some chains have better policies than others on this. I've found that the pharmacies of the two big grocery chains in my city are a bit easier to deal with than CVS and Walgreens. So if your supermarket has a pharmacy, inquire about what policies it has about filling orders for the drugs you need. Also ask the same question of the other pharmacies, big and small, that are located somewhere reasonably close to you. Once you've found a pharmacy that is more accommodating you may want to move your business there. I know from decades of experience that pharmacies are not all the same. There can be significant differences between them, so the time spent checking them out may help reduce this kind of problem.

 

[cbg]

But is it CVS that is requiring the pre-auth? Or is the pre-auth required by the terms of the insurance contract? If, as I suspect, it's in the insurance contract, changing pharmacies is not going to solve the problem.

 

[Tax Counsel]

But is it CVS that is requiring the pre-auth? Or is the pre-auth required by the terms of the insurance contract? If, as I suspect, it's in the insurance contract, changing pharmacies is not going to solve the problem.

I didn't think about that, and that's something that should be checked before going down the path I suggested.