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A Pharmacy's Duty Regarding Prior Authorizations: New Case Law

Does a pharmacy have a legal duty to notify a prescribing physician when a patient's health insurer informs the pharmacy that it requires a "prior authorization" form from the physician? This was the issue addressed in a heartbreaking recent case by the Massachusetts Supreme Judicial Court.

In the case, Correia v. Schoeck, the high court heard a wrongful death lawsuit brought by the estate of a 19-year-old woman, Yarushka Rivera, who suffered a fatal seizure after she was unable to obtain her prescription medication. Rivera had been diagnosed with epilepsy and prescribed Topamax, a medication she needed to control life-threatening seizures. Her insurer, MassHealth, paid for her Topamax prescription without issue on two occasions, but once Rivera 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. Rivera could not afford her medication without insurance.

Rivera’s mother filed a suit for wrongful death and punitive damages against Walgreens, the pharmacy in question, alleging that the defendants’ negligence caused her daughter’s death. She also sued her daughter’s neurologist, Dr. Shoeck, and his office, New England Neurological Associates, P.C. The mother claimed that Walgreens repeatedly told Rivera and members of her family that Walgreens would notify Schoeck of the need for prior authorization, but Schoeck and NENA both denied ever receiving notice.

In the Superior Court, the judge granted Summary Judgment for Walgreens—meaning, essentially, that a jury never had the chance to hear and consider the plaintiff’s claims. The judge ruled that Walgreens owed no legal duty to Rivera to notify Schoeck and NENA of the need for prior authorization.

The plaintiff appealed, and on its own, the Supreme Judicial Court took up transfer of the appeal. The high court explained that the concept of duty of care is derived from existing social norms, values, and policies. “In light of the evolving nature of the pharmacist-patient relationship, Walgreens's specific knowledge regarding the need for prior authorization, the industry-wide customs and practices of pharmacies handling prior authorization requests, and the foreseeability of the harm to Rivera, we conclude that Walgreens owed a limited duty to take reasonable steps to notify both Rivera and Schoeck of the need for prior authorization each time Rivera tried to fill her prescription,” the Court held. “The pharmacist-patient relationship is unlike that of a typical store vendor and customer. Pharmacists are no longer ‘confined to standing behind a counter and distributing prescription medications to patients,’ and ‘now also do many other things.’”

As some examples, the Court noted that pharmacists in Massachusetts are compelled to offer counsel to patients, to take certain steps to identify and prevent certain medical risks, and fill prescriptions correctly. “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,” the Court restated.

“Because we conclude that 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, we reverse the allowance of summary judgment for Walgreens,” the high court held. Walgreens's duty extends no further, however -- the pharmacy was not required to follow up on its own or ensure that the prescribing physician in fact received the notice or completed the prior authorization form. We conclude also that the judge erred in staying the accrual of prejudgment interest.”

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