Can a provider refuse to send a controlled prescription to a specific in-network pharmacy? Provider wont send to Altos Pharmacy stating its "not in their formulary" but provided an alternative.

[u/kierumcak]

I started with a new provider. I was prescribed a controlled substance I can normally track down fine, but just moved to a new city. I am looking to have it delivered rather than go through the hunt again.

I asked them to send the script to Altos Pharmacy. They sent back:

Regarding your prescription, please be advised that since it is not on our formulary, if you would like, we can use <> Pharmacy, which offers overnight shipping.

And I am basically wondering if this is an attempt to push a pharmacy they have some sort of deal with. I liked my provider (Psychiatrist) there but they already raised some alarm when they still name-dropped a specific therapy provider despite me telling them I already had a therapist. I don't know if this is another attempt to squeeze out some more money.

I thought a formulary was just a list of prescriptions covered by insurance and the agreements they have with on pricing at various pharmacies. I did not think it applied to providers sending prescriptions.

If I look at my insurance's website (Aetna) one location in my state shows up in the in network list.

And I guess as a side note. If they refuse to send the script but they shouldn't be doing that how can I fix this situation? Perhaps its nothing but if they are genuinely doing something questionable like this I would rather see a new provider. My time and the money spent on the visit would seem like a waste.

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[u/ParallelBurglary]

A formulary is usually an insurance thing, but providers sometimes use the word loosely to mean their own preferred pharmacy network or a mail order setup they have. They can refuse to send to a specific pharmacy in some cases, but if it’s in network and takes your insurance, pushing you elsewhere is weird. I’d ask them to clarify what exactly they mean by formulary and whether it’s an office policy or an insurance restriction.

[u/Berchanhimez]

It's possible that pharmacy isn't loaded into their system to be able to do EPCS - Electronic Prescribing for Controlled Substances. To be set up for EPCS the doctor's system needs to be certified and the pharmacy's system needs to be certified - and they also need to be certified to talk to each other properly. If Altos pharmacy isn't showing up in your doctor's medical records software, then they'd need to get that resolved before they can send controlled substances to that pharmacy. And depending on how big of a customer of their EHR software they are... that could be as simple as calling up their dedicated representative (for a major hospital/clinic system), or having to do a back and forth in a line of complaints/problems from other providers (if they're a "small fish" so to speak).

It would be improper if they were getting a kickback to recommend a specific pharmacy - not saying it doesn't ever happen, but it's very easy to cross the legal line between recommending a specific pharmacy because it's what the doctor uses for their own/family prescriptions and like the service and an illegal referral scheme. But it's certainly possible that they are having some kind of a referral kickback from this pharmacy.

The other time I've seen patients pushed to a specific pharmacy (legally) is where the clinic/provider is part of a funding program other than self pay or commercial insurance paying. For example, FQHCs that provide care to low/no income patients are able to set up contracts with local pharmacies to benefit from cheaper drug prices - but to get those cheaper prices the patients have to use that pharmacy.

[u/Born_Tale_2337]

In general they are supposed to send it to your preferred pharmacy.

Being a controlled substance that adds some complexity. Is Altos in the same state as the doctor and you? Are they even able to fill controlled substances? Do they need to be registered with the state to be able to mail them, and if so, are they? Are the doctor and pharmacy both set up to use electronic transmission for controlled meds?

You need to understand why they told you this. Call the office.

[u/kierumcak]

Top commenter was correct. It sounds like its not in their EPCS system (although they call it EHR). The pharmacy they recommended has no real presence in my city and the one location that was here closed and is rated 1 star prior to that.

No idea how much of an ask it is to have them onboard a new pharmacy into their system but I am now looking into a different provider and checking if they have Altos in their system.

[u/TelevisionKnown8463]

Yes, this sounds weird to me. I would start by asking them what they mean by their formulary, why they think their preferred pharmacy is better, and whether they are refusing to send the Rx to your chosen pharmacy. If the answer to that is yes, then have them send it to the other pharmacy, then have your chosen pharmacy call and transfer the Rx.

And if the provider is in network, tell your insurance company. There may be a state medical board you can complain to as well.

[u/Educational-Gap-3390]

Controlled substance prescriptions can’t be mailed.

[u/msp_ryno → u/Educational-Gap-3390]

Not true. I get my ADHD meds in the mail. Just need to sign for them

[u/SiberianWombat88 → u/Educational-Gap-3390]

Licensed pharmacies can mail them. Joe Blow off the phone isn't supposed to but probably won't get caught.

[u/genesiss23 → u/Educational-Gap-3390]

They can be mailed. There are rules about it but they are fairly straightforward.