How do I get a prescription from my primary care doctor?

My son’s salivary gland got inflamed, so we ended up in the ER, and then at Rabbit Hospital. The doctor there gave him an antibiotic that actually made him start peeing blood. We went to Vineyard Medical next, where an ENT specialist prescribed him 400mg of Avelox which costs $50. He bought the pills thinking his primary doctor would just sign off on the script so he could grab them at the pharmacy, but today she told him that specific med is strictly for pneumonia or sinus infections—she won't write a prescription for it since his issue is specifically a salivary gland infection.

WHAT DO I DO IF THE SPECIALIST LITERALLY WROTE THIS DOWN AS HIS TREATMENT IN HIS MEDICAL HISTORY??????

Lisa Brown4 said:My boyfriend ended up in the ER because his salivary gland got inflamed, and then we went over to Rabbit. The doctor there gave him an antibiotic that actually made him start urinating blood. So, we headed to Vineyard instead, where an ENT specialist prescribed him 400mg of Avelox, which costs $50. He bought the pills thinking his primary doctor would just write the prescription and he could go to the pharmacy using insurance, but today his doctor told him that Avelox is only approved for pneumonia or sinus infections. She said she can't write the script for it since he's dealing with a salivary gland issue.

WHAT DO WE DO IF THE SPECIALIST STILL WROTE THAT MEDICATION ON HIS MEDICAL HISTORY AS THE TREATMENT??????

Honestly, there isn't much you can do. It doesn't matter if a specialist wrote it or recommended it. The drug isn't being used for the specific conditions Medicare covers it for (in this case, it was prescribed for a salivary gland issue, but Medicare only approves it for pneumonia or sinus infections), so you're going to have to pay the full price out of pocket. If a doctor tries to misrepresent the diagnosis—like writing down a condition that is covered just to get the insurance to pay for it when you don't actually have it—and a Medicare auditor catches them (and trust me, they catch EVERYTHING because the whole system is interconnected), they’ll hit that doctor with a fine of $5,000-$3333. $50 isn't a lot when it comes to health 🙂, but that kind of penalty is massive.
I guess it's all pretty clear 🙂

Lisa Brown4 said:My boyfriend ended up in the ER because of a salivary gland infection, and then we went over to the local community clinic. The doctor there gave him an antibiotic that actually caused him to start urinating blood. After that, we headed to the Mayo Clinic, where a specialist (an ENT) prescribed him 400mg of Avelox, which costs $50. He bought the pills thinking his primary doctor would provide the prescription so he could just head to the pharmacy and handle the insurance side of things, but today his doctor told him that Avelox is strictly for pneumonia or sinus infections. Apparently, she won't write the script for it because his issue is specifically a salivary gland infection.

WHAT DO WE DO IF THE SPECIALIST LITERALLY WROTE THAT DRUG AS THE TREATMENT IN HIS MEDICAL HISTORY??????

The Secretary of Health needs to be replaced immediately. That’s the only way to fix this. And don't even get me started on the administration.

The guy is dealing with complications from the first antibiotic he was given, and now he can't even get the second one because of budget cuts and some official wanting to brag about how they reduced healthcare spending.

Lisa Jackson84 said:The Secretary of Health needs to be fired immediately. That’s the only way. And don't even get me started on the administration.

The guy is dealing with complications from the very first antibiotic he was prescribed, and now they won't give him the second one just because they're pinching pennies so the HHS Secretary can brag about how much money they "saved" in the healthcare budget.

Doesn't that lab report say a primary care doctor is allowed to prescribe a different medication instead?

Lisa Jackson84 said:The Secretary of Health needs to go, immediately. That's what should happen. And don't even get me started on the administration.

The guy is dealing with complications from his first antibiotic, and now he can't even get the second one because they're trying to cut costs just so some politician can brag about how much money they saved the healthcare system.

I guess I agree that the Secretary could be doing a better job fixing things in healthcare. But honestly, I don't know of ANY country where healthcare is 100% free and you basically never have to pay out of pocket. Now, someone will probably argue that we pay into it through our payroll taxes, which is true, but when you look at the actual cost, those deductions feel too small yet somehow still huge at the same time. Especially considering everyone from workers to retirees, and the fact that the US spends trillions on healthcare every year. We see it on the news all the time—little mistakes happening constantly, whether it's because of a doctor, a lack of equipment, or just poor conditions and funding. I don't really know what to say about it all, but it feels like this current model just isn't working anymore. I mean, what good is "free" healthcare if it's actually no good? I guess I just don't know...

Sarah Patel said:I honestly feel like the Secretary of Health could be doing a much better job resolving certain issues within our healthcare system. But personally, I can't think of a single country in the world where healthcare is 100% free without practically any out-of-pocket costs. Now, someone might argue that we pay into this through our payroll taxes, which is true, but when you look at the actual cost, those deductions feel insufficient yet somehow still heavy. Especially when you consider the balance between the working population, those out of work, and retirees, and the fact that the US spends hundreds of billions on healthcare annually. We see it on the news every day—little bit by little, some error occurs, whether it’s due to a doctor, a lack of equipment, poor conditions, or just a lack of funding. I don't really know what to say about all of it, but it feels like this current model just isn't working anymore. After all, what good is "free" healthcare if the quality is nonexistent? I just don't know...

I'm sorry, but could you please explain what exactly you mean by "100% free" regarding our healthcare? Is it perhaps the supplemental insurance I pay for? Or maybe the percentage taken out of my paycheck? Please, enlighten me.

I really hope someone takes a lesson from this situation.

Please, let's keep the political debates out of this; this PDF isn't designed for that kind of back-and-forth. Thanks!

fadedmarlin402 said:I really hope someone takes a lesson from this example.

And what would that be?
Are we supposed to just show up to any doctor without checking our coverage and knowing the costs beforehand?
Unfortunately, for some people, $50 massive amounts of money (setting aside the whole debate over universal healthcare) are on the line, so I think it's only fair to give them a heads-up.

jadesailor14 said:so what would that look like?
I mean, we shouldn't just show up to the doctor without knowing our coverage or what things actually cost, right?
I guess for some people, $50 a huge amount of money (aside from the whole debate over universal healthcare) is involved, so it feels fair to give them a heads-up about those costs.

With different insurance tiers, you'll know if you're paying a copay or the full price for meds. If your doctor hands you a specific type of prescription, you'll know where you stand.
Whether 15% of your paycheck is a lot or not for all the procedures and tests that everyone gets access to because of that 15%... I don't know. I just know the healthcare system is basically broke, and from what I can see, it probably won't be able to keep this up much longer. That's just my take (not trying to start anything or make laws or whatever 🙂 ).

I definitely know what all those different prescriptions mean
but how are you supposed to handle things like in the opening thread? When a specialist writes you a script but you can't just sit around waiting for a shift change to catch the doctor, so you leave your money at the pharmacy only to end up empty-handed

Honestly, I don't even want to get into the whole healthcare costs debate right now
But for the last six months, I've been "visiting" my neurologist, and every single month my appointment gets pushed back. Yesterday, I showed up at the clinic at 10:00 AM, scheduled for 11:00, only for the lady to have already headed home because she decided she wasn't busy enough
She runs her own practice, has a huge pile of patients booked, and she just bailed???? She decided there wasn't enough work to do???? Despite all of us sitting right there by the counter with a full sign-in sheet?????
I work in corporate finance, mostly dealing with paperwork, and I have never—not once—walked away from a job or a meeting just because I felt like it, nor have I ever shown up for a meeting only to have the other party completely ghost me
This was my third time having to take a day of vacation and spend money on gas, and it feels like such a slap in the face
Not just to me, but to a whole crowd of people
My next appointment isn't until October 29th.
Maybe we'll actually manage to see each other before the year is out!😬

This time, I actually agreed to see a substitute doctor instead.
Seriously, I haven't seen someone that arrogant, rude, and totally indifferent in a long time

And that, right there, is where 15% of our paychecks go down the drain
I’m a finance person, so I understand numbers and business models, and I get that the healthcare system is in debt, but they sure are quick to hand out those kinds of payouts
Yet when it comes to actual investments or equipment that gets bought but never used... we don't hear a peep about that...😁

My solution is to just go to a private specialist. But even if it sounds selfish, I feel like I’m entitled to some decent service after paying into this tiny little fund for 25 years (my salary is decent, and the amount I contribute to insurance could probably pay some people's entire monthly wages). Luckily, I can afford it, but most people simply can't

Oh, and yeah, I've been holding an appointment for an MRI since April 30th, 2010.😁
Thank God I only have multiple sclerosis; if I had a brain tumor, I could have passed away six times over by April 30th

Sorry, fadedmarlin402,
I just got a bit carried away by all this!😁

jadesailor14 said:And yeah, I’ve been sitting on an MRI appointment scheduled for April 30th, 2010, for a whole month now. 😁
Thank God I have MS; if I had a brain tumor instead, I could have kicked the bucket six times over by April 30th.

So, where did you book if the wait time is that long?
At Medikol, you're looking at a two to three-month wait.
Earlier this year, I actually ended up paying out of pocket for my MRI, but then Medicare reimbursed me because the scan proved the neurosurgeon was right all along.

Anyway, back to the medication issue.
I pay for my own meds because they aren't covered under Medicare.
From what I’ve gathered, if a specialist prescribes a drug that isn't on the Medicare coverage list, the hospital is supposed to shoulder the cost. The catch is that you'll rarely find a specialist willing to prescribe anything off-list, especially when the price tag is astronomical.

feralridge3 said:Where did you order yours if the wait is that long?
At Medikol, you're looking at a two to three month wait.
Earlier this year, I actually ended up paying out of pocket for an MRI, but Medicare reimbursed me because the scan confirmed the neurosurgeon was spot on.

vineyard
Well, that’s exactly what I did!
This is just a perfect example of how our healthcare system works.
Sadly, there are people who just can't navigate all these hoops—especially when nobody's willing to help guide them—and they end up stuck without the cash to pay upfront at places like Medikol while waiting for a refund.

jadesailor14 said:vineyard
well, I actually put this together myself
this is just a perfect little snapshot of how our healthcare system operates
unfortunately, there are people out there who simply cannot navigate all this bureaucratic nonsense—nonsense that nobody bothers to explain to them—and they end up stuck without the cash to pay for their prescriptions upfront while waiting for a reimbursement check that might never come.

It’s rare to find anyone willing to walk you through the labyrinth of health insurance, which is why forums like this exist. 😁
Still, you learn the most from your own mistakes. 😍
Very few medical professionals are actually going to sit you down and list everything you're entitled to.
That’s why you have to dig, snoop, and do your own homework. 😉

Honestly, those social interactions are driving me a little crazy! 😬
My mom used to work at a hospital (dealing with the same social issues), and she’d constantly have elderly folks cornering her in the hallways, trying to lecture her on what they thought were the rules...
The internet is absolutely incredible, but man, you see so much confusion in hospitals. Even with younger people who you'd assume are tech-savvy, if you tell them to just "Google it," they give you this look of pure bewilderment

Just digging and digging here!
I feel like a tiny little coal miner 😬

We’re getting a bit off-topic here.

I just wanted to add that finding actual information is such an uphill battle. It feels like my doctor barely scratches the surface, giving me nothing but the bare essentials. Meanwhile, everyone in my circle is just telling me, "Oh, you should ask more questions." But how am I supposed to know what to ask if I don't even have the baseline info to begin with? 😁

That being said, despite all the frustrations, I still think our healthcare system isn't a total disaster. Honestly, if I had to pay out of pocket for everything, I would have gone bankrupt a long time ago. 😢

Lisa Jackson84 said:Sorry, but what exactly is "100% free" about our healthcare system? Is it the supplemental insurance I pay for? Or maybe that 15% tax taken straight out of my paycheck? Someone please enlighten me.

Or maybe it’s the fact that we’re basically forced to go to private clinics and pay out of pocket because waiting for an appointment through the system takes three months—and who knows if you'll even make it that long. Plus, when you finally get in, it's just a massive headache and a total waste of time and money that's already being stripped from our paychecks every single month.

So, I’ve been dealing with some pretty persistent stomach issues for about two and a half years now. I’ve actually seen two different primary care physicians during that time—mostly because I’ve had to move around quite a bit—and honestly, neither of them was willing to refer me to a specialist to figure out what's actually going on. Now, I’m back seeing a third doctor since I’ve moved once again!

Since things have only been getting worse, I decided to go ahead and pay for a full check-up through my employer's wellness program at UnitedHealthcare, and thankfully, they’ve already scheduled me for a gastroscopy this Thursday! The procedure itself is covered under the plan, but I still have to cover the cost of sending out samples for analysis, which is $100, plus the H. pylori test comes to $100. That brings the total to $700. It’s a bit much, especially since I’m currently unemployed—I basically had to set aside everything else just to afford this!
Now, I’m wondering—if the doctor does prescribe something, am I expected to pay for all those medications out of pocket, or can I take the prescription to my regular doctor to handle it through my insurance?
I’m particularly concerned because if it turns out to be a treatment for H. pylori, we’re talking about a regimen of three different antibiotics!

Also, does anyone know how it works when you see a private gynecologist? Do you still need to bring a specific referral or a prescription from your primary doctor to get anything covered?

Emily Fisher26, you should be able to get a prescription from your primary care doctor even if your exam was done privately at a clinic like Mayo Clinic.
I personally go for a full checkup every three years at private medical centers—since my employer sets those up for us—and my doctor always writes me the necessary referrals and prescriptions based on the results they provide. You just need to bring their report along with you. Just stay firm and don't let them brush you off!

Thank you so much!🙂

Honestly, when you're dealing with this stuff, you really feel like you have to be your own expert—knowing exactly what’s going on with your health and understanding all the laws and patient rights—just so nobody tries to take advantage of you.🙄

I truly appreciate the help. To be honest, I've only been able to manage this level of care because I've had to navigate it all myself—my doctors here have a habit of just brushing me off—plus, we've already dealt with the loss of a family member to stomach cancer... and I can't help but think if I have to pay out of pocket for one more thing, I'll be completely broke!

So, thank you again!👍🙂

Emily Fisher26 said:Look, I’ve been dealing with stomach issues for two and a half years now. I’ve seen two different primary care doctors—I had to switch them because I moved around a bit—and honestly, neither one would bother referring me to a specialist to actually find out what's going on. Now I’m back with a third doctor because I moved again!

Since things are just getting worse, I decided to pay for a full checkup through my employer's health plan at Sun, and of course, they finally gave me a referral for a gastroscopy this Thursday! My insurance covers the procedure itself, but I have to pay $100 for the lab work, plus another 100 for the bacteria test. That brings the total to $700. Just keep in mind, I’m currently unemployed, so I had to scrape together every penny to afford this by cutting back on everything else!
So now I'm wondering: if they prescribe some medication, do I have to buy everything out of pocket, or can I go back to my doctor to get it covered?
Because if it turns out to be treatment for H. pylori, we're talking about three different antibiotics!

Also, does anyone know how it works when you see a private gynecologist? Like, do you still need a prescription or a formal referral from your primary doctor???

Generally speaking, a primary care doctor will respect a specialist's findings regardless of whether you saw them privately or through your standard insurance provider. This means they should write you a prescription if an internist or gastroenterologist recommends it based on those gastroscopy results...
As for the OB-GYN situation... every patient has the right and the responsibility to choose their own primary providers—your GP, your dentist, and your gynecologist. In the US system, your regular doctor isn't usually the one issuing referrals for specialized hospital exams or anything following that. You essentially pick a gynecologist specifically so you *don't* have to keep seeing them for every little thing. But when a private doctor prescribes something, the rules shift a bit. Every doctor puts their own reputation on the line for the treatment they prescribe. Because of that, insurance companies aren't necessarily obligated to cover a prescription for something the doctor didn't personally diagnose. If the diagnosis is wrong, the buck stops with them. Personally, I think they should respect a colleague's opinion, but everyone's experience is different. Some doctors will write the script and some won't; it's ultimately their call and their liability. Though, technically, they can always note the specialist's code to show they're following someone else's lead...
Did I help clarify things, or did I just make it more confusing? 🤷