Court Rules Pharmacies Have a Duty to Notify Patients of Insurance Issues After Woman's Death

Pharmacies may have a legal obligation to notify patients and their doctors about insurance issues, according to a case ruled by the Massachusetts Supreme Judicial Court on June 8.

The case is centered around the death of 19-year-old Yarushka Rivera. Rivera was prescribed Topamax by a hospital physician to control seizures after having her first one in May 2009 at the age of 18. During the same month, she saw a neurologist, Dr. Andreas Schoeck, who agreed she should continue taking the medication.

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Rivera’s medication had been covered under MassHealth, the state’s joint Medicaid and Children’s Health Insurance Program. Her family was able to get her medication with no issues until July 2009. When they picked up the July prescription, they were informed that the next prescription would require prior-authorization from the prescribing doctor in order for MassHealth to cover it.

Rivera was turning 19 in August, and MassHealth requires authorization for people over the age of 18 to show “medical necessity and effectiveness” and that a generic medication couldn’t be used instead. While picking up the July prescription, the pharmacist told them to inform Schoeck about the prior-authorization form. The pharmacist also said Walgreens would notify Schoeck as well, according to Carmen Correa, Rivera’s mother.

There was no evidence that Walgreens contacted Schoeck, according to court documents. From July to October, Rivera’s stepfather contacted Schoeck’s office at least seven times about the prior authorization form. After a second seizure in September, Rivera received a small amount of Topamax from the hospital and a new prescription for it. When they tried to fill it, they were told they’d have to pay the full amount, $399.99, for it. The family could not afford it, so Rivera continued to go without her medication. The pharmacist at Walgreens again said they’d contact Schoeck, but there is no record to indicate it reached out to her doctor.

The family tried four times to fill the prescription in September and October, but the prior authorization forms were not completed. Rivera’s mother and stepfather said they would have tried a different pharmacy if Walgreens hadn’t assured them the paperwork would be obtained. No Walgreens employees remember trying to communicate with Schoeck’s office.

At an appointment with Schoeck in October, ten days before Rivera’s death, she told Schoeck she hadn’t been able to take the medication. He told her his office would look into it. Schoeck and his office maintain they were never contacted by the family or Walgreens.

The Supreme Judicial Court’s ruling, which overturned the lower court’s decision that Walgreens did not have a legal obligation to notify the doctor, allows the family to sue the company for wrongful death. Schoeck and his practice are also named in the lawsuit.

The court said Walgreens had “a limited duty to take reasonable steps to notify both the patient and her prescribing physician of the need for prior authorization each time Rivera tried to fill her prescription.”

Because the pharmacy is the entity that submits reimbursement claims to insurers, patients and doctors are not notified of prior-authorization forms. This means the pharmacy is responsible for notifying patients and their doctors.

Though pharmacies have a duty to notify patients and doctors, it is not their responsibility to follow up with the doctor about the form or ensure the doctor received the notice, the court ruled.