Prior authorization was necessary in order for the plaintiff to obtain insurance coverage for Topamax, a medication she needed to control life-threatening seizures. The plaintiff’s insurance company paid for her Topamax prescription twice without issue, but once she reached her nineteenth birthday, the insurer refused to pay for the prescription because it had not received the prior authorization form required for Topamax patients over the age of eighteen. Her family made numerous attempts to obtain the prescribed medication from her pharmacy, but to no avail. The plaintiff was unable to afford the medication without insurance, and suffered a fatal seizure.
The Supreme Judicial Court of Massachusetts held that the pharmacy had some duty to advise the prescribing physician of the need for prior authorization.
“The pharmacist-patient relationship is unlike that of a typical store vendor and customer.” The Court then summarized some of the statutory obligations that a pharmacist has to take steps to identify and prevent medical risks to a patient. “That these statutes and regulations refer to those obtaining prescriptions as ‘patients’ rather than ‘customers’ also indicates that the relationship between pharmacist and patient goes beyond that of a typical commercial relationship. Thus, while pharmacists are not required by law or regulation to facilitate prior authorization processes for patients, it is evident that they have some role in furthering the well-being of their patients, and are well situated to assist patients with certain issues regarding their medications.”
“Walgreens conceded at oral argument that it has a duty to notify the patient of the need for prior authorization, but maintains that it has no duty to notify the prescribing physician.” The Court, however, found that: “A pharmacist exercising the skill and knowledge normally possessed by members of the professional community ordinarily would notify a patient and the prescribing physician that prior authorization is needed…. Notice to the patient, however, is insufficient to discharge the pharmacy’s duty. It is particularly important in these circumstances that the pharmacy also notify the physician directly to avoid foreseeable harm.”
The Court made it clear, at the same time, that pharmacies were not required “to monitor or supervise prescribing physicians…. The duty we recognize in this case…does not require pharmacies to control the actions of prescribing physicians by, for example, imposing enforcement mechanisms should a physician fail to complete a prior authorization form. Rather, pharmacies simply must take reasonable steps to notify patients and prescribing physicians that, if the physician wants a patient to receive insurance coverage for the prescribed medication, the physician must complete a form. Additionally, Walgreens’s concern that recognizing a duty here will expose pharmacies to liability every time payment is denied by a health insurer is unfounded. Our decision only covers situations where insurance coverage is denied specifically because a prior authorization form is required. Pharmacies can protect themselves from liability in these instances simply by notifying the patient and prescribing physician by any reasonable means, and making a contemporaneous record of having done so.”
Correa v. Schoeck, No.12409, 2018 WL 2729350 (Mass. June 7, 2018).