The Pharmacy Chick

Flying the coup in retail

Stupid Medicare Rules part 2-precision eye drops

Filed under: Uncategorized — pharmacychick at 10:16 pm on Monday, August 25, 2008

 If you are a pharmacist and you have had the pleasure of filling prescriptions under some third party, you understand the nightmare of “days supply”.  Its a hot issue right now and one under which a third party payer can play “gotcha” and take their money back. Make it too short and risk an audit, make it too long and you may have to call for a refill-too-soon override.   Regardless, the Chick tries to be rather generous on the days supply of 3 groups of medication:  Insulin, eye drops and inhalers.  For obvious reasons, you cannot have a stock days supply on these groups of medications.   Some D plans seem to have decided that they can indeed desginate a hard and fast days supply on eye drops.

The Chick was doing her thing filling a Cosopt rx for a new D patient.  This woman fills this rx on a pretty regular basis, every 30-35 days.  When I fill this rx, my own computer assigns it a 50 day supply but I override it to 30 days.  I have all the documentation I need to support the days supply I transmit because of her past schedule.  I filled the Rx only to be given a “rejt-invalid days supply–plan limits exceeded” by the insurance.  At first I thought I had transmitted something wrong but after a check, I realized it wasn’t me at all. I had to call the insurance, something I REALLY dislike doing.

After being on hold for way too long I finally get their representative who wants me to verify all kinds of information (just to be sure I am not some identity thief I suppose) that I had already inputted before she finally came on the line. Name, DOB, Rx number, NPI, Cardholder ID, Favorite color..etc before she finally relented and asked me what I need.

I explain the problem with the eye drops and she drops this little bombshell on me: Her plan limits her to 1 bottle every 56 days. AND according to THEIR charts, it should last 60 days. What the hell?

So lets do the math.  If you have the perfect dropper you (in theory) can get 20 drops per ml. A 5 ml bottle of eye drops have 100 drops in the bottle. IF you use 1 drop in to each eye once daily, AND never miss the eye, and have perfect technique, you will get 50 days out of the bottle.   Ms Representative would have none of my arguments.  Plan limits might as well be scripture carved in stone.  She wasn’t getting this filled as a 30 day supply.  It was also clear that when she runs out in 35 days that she was going to have to pay cash or beg for a sample til her D plan coughs up another paid claim.

Personally, I suck at eye drops.  If I get 1 drop in 3 in successfully, I dance for joy and all is right in my world. Usually the job falls to Mr Chick, holding me down, prying my eye open and promising me jewelry if I will sit still. So, If Pharmacy Chick-Pharmacist extraordinare cannot get eye drops in properly, what makes this D plan think that they can legislate that some 65+ yr old retiree with glaucoma and shaky hands will successfully negotiate eye drop insertion 100+% of the time.

You see my point?  Well you are the only one because this scenario has repeated itself several times over already. One man purchases Travatan out of pocket every other refill for this reason. Another purchases her Lumigan every other time for the same reason.  Its unbelievably pathetic because I cannot help.

Its a sorry state.  To all those people screaming for socialized medicine:  Heres a taste of what you’ll get.  Granted, our system is flawed, grossly flawed, but please.  Put the government in charge of your health care and you might as well say goodbye to your freedom of choice…and apparently the ability to calculate days supply.

Oh, and better start practicing on your eye drops now,  you’ll need to be pretty good at it.

9 Comments »

420

Comment by Pharmacist Erin

August 26, 2008 @ 8:56 pm

You are so right on the money about this… I absolutely hate days supply. And the customer thinks I’m telling them that they can’t get it filled. Yes, you can but you must pay cash. So frustrating.

421

Comment by Cathy Lane RPh

August 27, 2008 @ 10:44 am

I don’t get why the government would be more liable to be restrictive than the private insurer. In my way of thinking, currently the patient is limited to what the private plan dictates–don’t like it, the company will cancel, and I have been denied before, and had to go through further worry and expense of finding alternatives. I am of the inclination that if it’s a government program, citizens can complain collectively about the inequity of having to pay $150.00 (or the going price for a bottle of Cosopt)/month for their anti-glaucoma meds (to prevent blindness) whereas the erectile dysfunction people get theirs for the price of a single-copay (not that blindness is worse than a healthy sex life).

At least in the government, there’d be recourse with authoritative proof that blood cannot be drawn from a turnip, or that there are 20 gtts/mL of such and such, and therefore a legal leg to stand on. I mean, if there’s a government program, a worker CANNOT be denied insurance–for whatever reason, even for complaining of uneven handedness or unfairness.

As a single breadwinner in a family of four, having pre-exisiting medical conditions or having to use COBRA is enough of a nightmare to make one realize that you’re over a barrel in dealing with private health insurance companies.

422

Comment by The Ole' Apothecary

August 28, 2008 @ 8:57 am

Saying “pre-existing conditions” is like saying “Sahara desert.” “Pre-existing conditions” is the biggest insurance ruse of all time. You can’t get health coverage because you are sick. Can we say, “Catch-22?”

Chick, how do you stop and calculate drops and fight over this stuff while you fill 500 to 1000 prescriptions a day? If there is a Drug Medal of Honor, it should go to today’s retail pharmacy staffs.

Have you ever had to fight over the days’ supply of deodorized tincture of opium (C-II)? I had to, just on a controlled-drug basis, not on insurance. Imagine the double whammy of insurance and legality, especially if it is over a totally cantakerous cancer patient who deserves sympathy, but only up to the point at which they begin to use expected sympathy as a weapon to cut into your gut with.

423

Comment by bluetowelboy

August 28, 2008 @ 4:51 pm

Yeah, I don’t get why you think the government would be worse. The medicare part d program is currently not a government program except in name only. It is private insurance running with government money. The government pays the private insurance for the patients rx coverage so the only way for the private insurance to make more money per patient is for them to start denying medications, requiring PAs etc. Then they get to keep more of the money the government gave them because they are paying less to us in reimbursements.

Even though Regan said the scariest words in the English language were “I’m from the government and I’m here to help” doesn’t make it true. Private companies can and do have just as much malfeasance and government run institutions.

Just food for thought.

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Comment by pharmacychick

August 29, 2008 @ 10:03 pm

BlueTowel Boy,
I would have to beg to differ with you on this one point. It IS a government program, thru and thru. They contract with private insurers, yes, but if the money comes from the govt coffers, then its a government program. In addition, they set the guidelines, whats covered, what’s not, etc. What private insurance have you ever accepted that had a “donut hole?” There are certain rules that apply to MED-D programs that do not apply to non-medicare programs. They are entitled to certain “liberties” shall we say with regards to record keeping that has never been in place before now. You don’t say if you are a pharmacist. If you aren’t then you haven’t experienced the nightmare. I will agree with you that private institutions can and do have as much malfeasance, BUT I am also a firm believer in capitalism. If there is competition, there is the incentive to get better. Where there is one game in town, its their way or the highway.

425

Comment by bluetowelboy

September 2, 2008 @ 5:23 pm

First, I am a pharmacist. Secondly what you say is not entirely true. It is true that the private insurance companies get money from the government to run the plans. However it is not true that the government sets what is covered and what is not. That is why you have some things covered under one program and not others. That is one of the reasons it can be so difficult to choose between plans because some of the plans may not cover your medications where as others will.

I also am a believer in capitalism unfortunately that is not a system we see in place in healthcare today. Most people who have insurance get that insurance from their employer who offers maybe one or 2 plans. The employee has virtually no choice and once the employer chooses the plans that are available they are locked in. This gives the insurance companies leeway to pretty much run amok. If they change what is covered can you then change plans. No you cannot hence not really capitalism.

As for a one carrier system, have you ever asked anyone if they would give up their medicare? Chances are they would not.

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Comment by pharmacychick

September 2, 2008 @ 9:22 pm

Bluetowelboy,
Here is the point I was trying to make in your response. Medicare set down some certain rules regarding what they will cover, or NOT cover. According to the CMS, Med D will not pay for certain categories of meds including Vitamins (rx or not), and sleeping medications. These may or may not be discounted by the plan, but they do not apply towards TROOP. We use PDX and the pay screen will notify us. Perhaps I should be more specific, yes some plans will cover some items better than others, and you can bet that the higher the premium the better the overall coverage will be. That is also why people should check in detail before signing up for a particular plan.
As far as private insurance, I agree that most people have their insurance thru their employer. I still say its capitalism because the employer gets to choose. I didn’t say it applied all the way down to the consumer. As long as the employer pays for the insurance then the employee has to take whatever is offered. I get my choice of 3( which is better than none). I CHOOSE the most comprehensive although it costs me more becasue it gives me the most options. The employee still has the right to eschew any option and purchase fully private insurance tho it is likely not a financially viable option. I technically could purchase a lamborgini over the Honda I have, but its not a financially viable option, hence my options are more limited.
Lastly, regarding if a person would give up medicare–If there were a better option, I’d bet they would in a heartbeat. I hear many complaints about the complexity and the difficulty with getting healthcare. Many Dr’s in our area are refusing medicare patients because they don’t pay enough. the issue is CHOICE, At a certain point, they dont have any more options. I cannot count how many people who had private insurance who CHOSE a medicare D plan and let the private plan lapse say “oh I wish I had stayed with my old plan, they promised it would be the same or better but its not.” Once they took the Med D plan, they closed the door and locked it behind them. No looking back. I had a dozen or so Tri-Care people lose their TriCare because they thought they were getting a better deal on a Local D plan. So Yes they would give up their plan.
Thanks for reading and I appreciate your insightful comments.
Chick.

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Comment by Daniel

September 19, 2011 @ 2:26 pm

Is pharmacy chick hot?depends
on your definition!

Comment by Wes Andersen

April 1, 2015 @ 2:44 pm

Single payer system could be no worse than the convoluted mess we currently live with. Pharmacy long ago sold its collective soul to the insurance companies who now seem to be owned to a large degree by pharma. And pharma handsomely pays the lobbyist to direct the dysfunctional and occasional decision makers in the hallowed halls of congress. I cast my lot with the single payor.

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