Neighborhood Pharmacy Versus Mail Order Pharmacy

Case Study: Neighborhood Pharmacy Versus Mail Order Pharmacy

Rishi Sardana is an 11-year-old boy who is being switched from regular Ritalin to Ritalin LA, the long-acting version. His father, Mr. Sardana, goes to the pharmacy to pick up the new prescription, but he is told that the insurance company is refusing to pay for the LA preparation. The upset father tells the pharmacy technician that the pharmacy did not do it right and he wanted the pharmacy to fix the problem. The pharmacy technician calls the insurance company to clarify why they do not want to pay for the LA preparation. The representative of the insurance company explains that Ritalin LA is a maintenance drug and the policy of the insurance is that maintenance drugs must be ordered through their mail order pharmacy program. The representative also explains that they sent information to the family about how to make the switch. The insurance company does agree to approve the drug at the pharmacy, but with a much higher copay. The patient decides to buy a 30-day supply at the pharmacy and then transfer the prescription to the mail order pharmacy program, which has a much smaller copay.

Discussion Questions

1. Identify the members of the team mentioned in this case study.
2. Discuss the responsibility of each team member for the failure in communication. Remember the patient is also part of the team.
3. Should the insurance company be part of the healthcare team? Explain your rationale.
4. The insurance company sent information to the Sardana family about changing Rishi’s prescription to the mail pharmacy. The communication of the health insurance company was not effective. If the team members involved in this case were working in collaboration, what other measures may they have taken to ensure the communication of this information was successful?

1. Members of the Team:
   • Rishi Sardana (Patient): The primary individual for whom the prescription is intended.
   • Mr. Sardana (Father): Acts as the guardian and decision-maker for Rishi’s healthcare.
   • Pharmacy Technician: Responsible for handling prescriptions, communicating with the insurance company, and dispensing medication.
   • Insurance Company Representative: Manages the insurance policy, coverage, and communicates insurance-related information.
2. Responsibility for Communication Failure:
   • Pharmacy Technician: They might have failed to inform Mr. Sardana about the insurance policy regarding maintenance drugs and the available mail order pharmacy option. However, they did take the initiative to contact the insurance company to resolve the issue.
   • Insurance Company: Though they communicated the policy, the effectiveness of this communication is questionable as the Sardana family was not fully aware of the mail order option and its implications on copayments.
3. Role of the Insurance Company in the Healthcare Team:
   • Yes, the insurance company should be considered part of the healthcare team to an extent. They play a crucial role in determining coverage, medication access, and cost, all of which significantly impact a patient’s ability to receive proper care. However, their role primarily revolves around the financial aspects rather than direct patient care.
4. Improvements in Communication:
   • Better Explanation by Pharmacy: The pharmacy could have proactively informed Mr. Sardana about the insurance policy for maintenance drugs and suggested the mail order option before processing the prescription.
   • Clearer Communication from the Insurance Company: The insurance company should ensure that their communication about policy changes, especially those impacting copayments and access to medication, is explicit and easily understandable by the recipients.

In a collaborative setting, the pharmacy and insurance company could have worked together to provide clearer communication about the policy and the mail order option, ensuring that the Sardana family was well-informed from the start. They could have sent written material or even made follow-up calls to confirm that the family understood the implications and choices available. Additionally, the pharmacy could have a protocol to inform customers about insurance policies that might affect their prescriptions before processing them, allowing for informed decision-making by patients or guardians like Mr. Sardana.