This week we received a reader comment about a topic we haven’t yet addressed around being charged for a (potentially unnecessary) office visit for prescription refills. Below is a summary of her question and our tips to avoiding prescription refill issues and unnecessary fees!
I’m having trouble finding helpful information around prescription refills and how doctors in the area (NYC) are charging full visit fees for refills. For example, I called the doctor for a refill which took about 5 minutes in total and they charged me over $100 after insurance (would have been almost $400 without it) to have my prescription refilled. Because this is something that is taken regularly, that means I would have to call back in a couple weeks and be charged another fee to get another refill. Any thoughts?
Understand legal, procedural, and/or policy prescription refill limitations for your specific prescription.
Some states, health systems, doctors, and insurers may have rules, laws, or policies to follow regarding the amount of any given prescription that they can prescribe at once, and/or the procedure for providing a prescription refill.
State-level Prescription Refill Limitations
Begin by Googling your prescription and state (ex. Levothyroxine Prescription Limitations North Carolina) to understand if there are state-level restrictions about your prescription’s supply or refill policies. For example, regulations in New York limit an initial opioid prescription for acute pain to 7 days.
Health Insurance Prescription Refill Limitations
Next, check your health insurer’s policies around your prescription.
Most commonly, you’ll find that some drugs require a Prior Authorization, meaning your doctor must provide written documentation supporting the coverage of your prescription.
You may also encounter Step Therapy, a process that requires you to try other, similar medications that are on your insurer’s approved drug list (formulary), to see if those drugs provide the benefits or relief that you and your doctor are seeking.
Some drugs are simply not covered by your insurance. Each insurer typically has a searchable, online list of covered prescriptions. To find the list, Google [Insurer Name, Approved Drug List]. You may need to create an online account and login to see the details specific to your plan. Some links to common insurer’s approved drug lists are below.
If your prescription is not subject to no coverage, step therapy, or prior approval, determine if there are any limits on the amount they will cover with each refill. Most prescriptions are prescribed in typical dosage and quantity amounts, and if your doctor is prescribing outside of those typically filled amounts, your claims may be flagging in the insurer’s system. If you have questions about these amounts and cannot find what you are looking for on the insurer’s website, call the number on the back of your insurance card to ask questions specific to your medication.
Provider-Level Prescription Limitations
Many health systems, group practices, and individual doctor’s offices have their own policies regarding prescription refills. If your prescription issue is coming from your provider’s office, it is important to talk to the office manager to understand what their policies are.
Required Office Visits for Prescription Refills
If your provider is requiring you to come in for an office visit every month in order to have your prescription refilled, ask the office manager if that is a standard office policy, if it is specific to your medication/condition, or if there is some other reason.
If the only reason you have to come in for a visit is due to that office’s policy (not a state law, your insurer’s policy, or because it is highly recommended given your condition), you may want to explore other in-network providers who work for different practices with different policies.
Learn more about finding an in-network doctor here, and be sure to ask the new provider what their prescription policy is before getting a second opinion or transferring. It may be worth talking to several different office managers at different practices to get a feel for the new practice’s communication style and policies before transferring your care.
Writing Prescriptions in a Limited Supply
If your provider is writing prescriptions for a very short supply and there are no legal, clinical, or policy reasons to support that practice, you may also want to explore other doctors. Most insurance companies actively encourage 90-day mail order supplies of maintenance prescriptions to reduce the overall cost and logistics for them, the patient, and the provider, so staying with a provider that is not willing to lengthen your prescription when it is allowed and even encouraged may not be in your best interest.
If you are unsure about your specific medication, speak to the office manager of your current practice and to your health insurance provider about your medication’s allowances, and look for second opinions if there is any misalignment.