In August, a Veteran experienced a four-day delay in receiving a drug prescribed by an Emergency Room (ER) physician for an acute condition. The ER doctor prescribed a drug that the Veteran learned, after two pharmacy visits, required special authorization from Medavie Blue Cross (MBC). Unable to afford the up-front medication cost, the Veteran contacted the Office of the Veterans Ombudsman for help.
The OVO intervened immediately, but four days later received an initial VAC decision to deny approval for the ER-prescribed medication. VAC told the Veteran to visit another medical practitioner to obtain a different prescription for a pre-approved drug. Once again, OVO intervened and VAC issued an “exceptional” approval so the Veteran was able to fill the original prescription. VAC also agreed to consider the prescribed drug for inclusion on their approved list of medications.
Finally, when following up with the Veteran, it was the OVO front-line rep who communicated news of the approval so that the Veteran was able to obtain the required medication. VAC had not immediately communicated the decision to the Veteran.
The OVO identified five issues and contacted VAC to determine what steps they could take in the future to prevent this from recurring. VAC has responded (see below), and the OVO hopes that these positive steps will result in better service for Veterans.
- Medavie Blue Cross (MBC) needs a 24-hour phone line for pharmacists to call. VAC responded that their National Pharmaceutical Advisor is reviewing the special authorization criteria associated with the prescription drug in this case. Any recommendation changes will be brought forward to the Formulary Review Committee for review and implementation. In addition, VAC states that this particular drug will also be considered for addition to the interim supply list. VAC’s Prescription Drug Team will also ensure the 24-hour pharmacy is contacted to investigate why they did not receive the message with the answering service number.
- Drugs prescribed by an Emergency Room physician require immediate approval to ensure Veterans do not experience delays in accessing necessary treatment or suffer from unnecessary financial hardship.
- Veterans should not be made to seek additional medical care while suffering from an acute medical condition. With respect to points (2) and (3), VAC noted that in this situation, a gap was identified in the process – specifically, when a prescription for a special authorization drug is received after hours, and the particular drug is not included on the interim supply list. VAC states that its Prescription Drug Team will bring this gap forward to be discussed at the next Formulary Review Committee meeting. The Committee will be asked to consider putting any special authorization drug requiring a medical consultation on the VAC interim supply list so that the Veteran can receive immediate treatment. VAC will then advise Medavie Blue Cross (MBC) of the resulting recommendation and have it implemented so that the gap is filled going forward. In addition, the Prescription Drug Team will provide information on the updated process to the OVO once the recommendation is implemented.
- Urgent situations require capacity for same-day VAC decision.
- VAC needs to take charge of client contact and follow-up. With respect to points (4) and (5), VAC stated that its Prescription Drug Team will continue to expedite decisions for urgent inquiries and will make contact with the Veteran directly as required. VAC’s Prescription Drug Team will evaluate future scenarios similar to this situation and make further adjustments to the prescription drug process as required.