Your stupid paper card is just that…

Posted by The *Angriest* Pharmacist as Drug Companies, Drug Topics, Education, Laws, PHARMACY SECRETS!, Patient Education, Robbery, Stupid People, True Story

Happy Super Bowl Day! I don’t watch much football. I’m a BASEBALL fan, myself, but I will get drunk and scre eat some wings with my wife.

I know you’ve seen these stupid ass little paper cards floating around in magazines and periodicals. They are laid out like your standard insurance card, and they do a great job at tricking stupid people into thinking they are insurance cards. What I don’t understand is how someone could be so dense as to think that, “I bought a magazine / insurance policy last Tuesday. On Wednesday, I went to the pharmacy and got all my ’scripshuns filled up for free….that insurance I bought for $3.99 was awesome! Celebrex for free? DAAAYYYUUUMMM!” [You now hear and see me beating myself about the head with my stack of bathroom Drug Topics]

I’m now going to drop some serious knowledge on the non-pharmacy people of the world. Pharmacy Secrets numero leche con wavy lays.

- Amphetamine XR 5mg has an AWP** of $100 for 30 capsules
- The true cost to the pharmacy for #30 caps is AT BEST usually around 20% less than AWP. Most of the time, it is closer to 15% these days (the bulleted list below explains that). So, we can paid $80-85 to acquire.
- So the Pharmacy will put in the computer system that we bought the drug for 80. There will also be an AWP field. We put 100 in there. [This is for simplicity. In reality, AWP is calculated by taking the AWP per the number of caps in a stock bottle. So AWP is 138.99 for a 60 count bottle, AWP is input as   2.3165 (138.99/60). Cost is the same way.
- Insurance companies get the claim and, to them, it looks like we are telling them, “Hey, this medicine COST us $100 to fill. We need that to break even.”  -- Well ins companies know how the game is played and they tell us to piss off. They know AWP is set at 20% above our cost. So, they pay accordingly. The most common equation is AWP-10% to AWP-15%. Sometimes, there is a constant put in. For instance, AWP-10%+$3. Whereas, the $3 is considered a dispensing fee. It helps increase profits for pharmacies, but usually means that the percentage is going to be LARGER…
- Going by these methods, we would get paid:   $85 to $90      if using just AWP-10/15%  [+/- $3 depending]. If I make $85 dollars on an $80 prescription, can I afford the pharmacist, technician, computers, utilities, paper, support staff, telephones, and just about a million other costs associated? Absolutely not. How does this work? Ahh…you’re forgetting the COPAY! That….she’s a mine! So, Amphetamine XR is a generic, but it’s a new generic…still made by the BARR, the brand name manufacturer. Hell, even the numbers/symbol on the cap is the freaking same. I’m not sure what the copay would be, but let’s say it’s 25 dollars. That means that I actually made $110 on the $80…which is a gross margin of  27%. That’s pretty good for a pharmacy in 2009. To really stay competitive and continue living, you need to get some 30%+ in there as well….to balance w/ the next bullet:
- $4 prescriptions. So, we are charging $4 absolute to the patient. We can say the AWP=$4 then. The cost is NOT usually 20% less on these…it’s actually MUCH less (WM wouldn’t have thunk it up otherwise). Cost on $4 rxs range from $0.20 to $2.50 for others. Average would be around $1.25. That means that we only make $2.75 per Rx average. While the gross margin appears to be good on this, at 30+%, it’s a TRICK – think economy of scale. It costs just as much to fill this single prescription that is going to net me $2.75 profit while your Amphetamine is going to net me $30. Same amber vial, pharmacist, technician, labeling, etc….and we’re filling a lot more$4 rxs than ever before due to doctors using them to dictate their prescribing habits.
- How does insurance figure in on these? They don’t. While we are required to submit the claim to them, as they track the patient’s utilization of their benefits and ensure compliance for their own records, they don’t pay us a cold damn cent. In fact, it COSTS us a nickel to 15 cents to process the damn claim – like it’s dialing a long distance fucking call…bogus! The claim submits, and comes back with the cost the same, AWP acknowledge, and third party paid $0.00. But, don’t forget the copayment! Some insurances have flat copays of $8 for generics (even though $4 is less than $8,right? Duh.) So, the patients would most likely say, “Take it off my insurance! Just bill it cash!”  Across the country this is happening for third party claims – private insurances and medicare part D. Now I’m not sure about the private ins claims and a patien’ts contract with them, but I’m 100% positive that it is illegal for a patient enrolled in medicare to not utilize their benefits – even if the benefit may be a detriment at the time. People do this like crazy to avoid “the donut hole” as if $4 is going to get them there with any haste. I don’t fight people on it because I know they’ll never charge someone for evasion, but it is certainly illegal to do this for Part D — and it’s fucking immoral if the patient is on Medicaid. If they have Medicaid and can pay cash, they need to be paying cash and removed from the Medicaid register. Why is this illegal? Because. Because medicare wants to track patient compliance. Medicare wants people to use up their eligibility and MAKE it to the donut hole – then medicare can really start letting the patient have it! I dunno if they make any money, but they certainly LOSE MONEY AT A SLOWER PACE when a patient is eating doughnuts.
-  As a funny aside, Medicare sends these old fogies these printouts of the drugs they’ve gotten, what we billed to medicare, and how much money has been changing hands. I get fucking screamed at for these stupid ass pieces of paper once a week and these dumb printouts say dick and mean even LESS than dick. What they show people is the following.

Pravastatin 40mg Rx#1234567    –    January 27, 2010
What Your Pharmacy Billed to us:   $75.29
What you paid for copays:          +    $3.30
The total of these 2 rows is:         $78.59
^{(the amount we actually paid your pharmacy is $0.00)}

I bet you’re wondering what the infinitely small line of text is:
(the amount we actually paid your pharmacy is $0.00)

What the point in sharing this information with an old person? Not a damn reason one other than to get ‘em all riled up and hope they die of a heart attack before being beaten to death by their pharmacist. All these old people see is that bottom line. Now…why did they add that column? Because that’s what you do with columns…you add the mofos!  They have nothing to do with each other. And that “billed to us” is a joke. That’s the AWP at work…being worthless. Pravastatin is a drug that the AWP has never fallen. We get it for less than 5 bucks per bottle of 100 and the AWP is still hundreds….the insurance companies are well aware of the $4 rxs as well as the COST of each medicine as it’s available to each chain – they know all and see all. They pay nothing.

Now, to finally answer your question – it’s exactly as above….except on every drug. Not just $4.

Some companies negotiate contracts with the drug manufacturers and that’s what dictates their formulary and the costs that the patient pays. For instance Amoxicillin is a $4.00 rx. We bill it to Anthem, they have a contract with us to give them discounts in specific areas. So, the copay comes back to the patient $2.75 cents. Then you look at what the 3^rd party actually paid — $0.00! This is precisely how those free cards work – only w/o the contracts. MY computer system won’t let me fill a prescription w/o at LEAST covering the cost of the medicine (what we paid)  plus 3 dollars. Well, since this Amox is 2.75, we didn’t cover that – no way! Since it’s $4, we’d let it slide, but a 3^rd party wouldn’t. But, it doesn’t say paid under cost. It’s good to go…cause of the contract my pharmacy has with anthem. We give them a discount there and somewhere else, we get a better deal – plus we get them in the store buying Tylenol and sodas and shit.

The freebies cards just manipulate the price down and hope that the pharmacist is a east Georgian Tard Hound. Hopefully, I won’t notice that this medicine cost me $50, the patient is being charged $30, and I was paid $0.00 by the third party….Well, I always notice – my computer system helps me. But, how in the hell does the free card company make money? They are in cahoots, if not MAJORLY owned by the drug companies. Bingo! So, the claim comes through when it’s filled and they know, badabing, we got a sucker. If it doesn’t get deleted after X days, they get a kickback from the drug company for essentially filling a script. The manufacturer still sells the drug to the pharmacy at the same price regardless – their only concern is to get them to buy more and more! Those cards aim to help…and aim to screw over your pharmacy.

ON AVERAGE: Calculating COST from AWP
• For single source innovator drugs: pharmacies purchased the drugs at an estimated discount of 17.2 percent below AWP.
• For all drugs without Federal Upper Limits of Cost (FULs): pharmacies purchased the drugs at an estimated discount of 27.2 percent below AWP.
• For multiple source drugs without FULs: pharmacies purchased the drugs at an estimated discount of 44.2 percent below AWP. A further breakdown of multiple source drugs without FULs showed the estimated discount for innovator multiple source drugs to be 24.4 percent and 54.2 percent for non-innovator multiple source drugs.
• For multiple source drugs with FULs: pharmacies purchased the drugs at an estimated discount of 72.1 percent below AWP.

If you don’t want to read the LONG version (attachments and info I’ve typed above and below this line, go to this link: http://www.volunteer-ehealth.org/frisse/erx/2007/05/prescription-drug-pricing-mac-can-make.html — It provides a hell of a good simplified synopsis of all the different acronyms in pharmacy costs and explains them well. Give it a look either way actually.

All things being equal

Posted by The *Angriest* Pharmacist as APhA, Disgusting, Drive-Thru, Drug Companies, Drug Topics, Errors, Management, Me being a dick, Me hating others, PHARMACY SECRETS!, Politics, Stupid People, Technicians, True Story, Work Sucks

Prereading for this post:   Walgreens has POWER (80 COMMENTS!)

I was going through some server logs and discovered something. This tid bit of information was shocking to me. The above post/link was and is being heavily monitored by Walgreens themselves. As you know, the bottom of each post I type has two links these days. One allows you to email a post to a friend using my server’s resources. The other link opens a printable copy of the post along with links and annotations.

The email function is heavily used across the entire site — very heavily used…and it is also logged for security purposes. Today is the first day I’ve looked at said log since implementing the function and verifying it worked eons ago. It’s been used by a plethora of people. From students spreading the funny advice, to bikers spreading stories about our little spat, to companies seeing what’s been said about their new policies and procedures.

Such as WAG… who used it to spread the post amongst their corporate headquarters and various offices. One employee sent it to a great number of other “@walgreens.com” email addresses some time ago stating, “it’s important we know this is circulating…” and “continued monitoring is necessary.” Several were sent as, “FYI per meeting agenda.”

I don’t have more information than that. Their hits from their walgreens IP address (which resolves to walgreens.com) number in the thousands to this site in the days to weeks following that post. I’m sure it’s blocked at store level — but they were watching.

So, my POWER Pawns — did anything change? In my area, I’ve noticed nothing of this program as I’m rural and not yet touched. As I said before, I’m excited. The Walgreens I compete with couldn’t possible provide worse customer service. We’ve actually stopped advertising in the local paper as they do it for us. POWER won’t do anything but make me money. Did we rattle their cage a little bit?

One of the pharmacists working at that store actually just quit a few days ago. Just walked out. Now he’s commuting over an hour to an independent pharmacy. He was filling more than 800 per day and never allowed more than 2 pharmacists, 5 techs and 1 dedicated cashier. They had a counting machine, he said, which accounted for about 25-50% of the volume, but it was constantly on the fritz. Remember what Drug Topics said a few months ago? It’s what I remind my coworkers of every time I catch a mistake — 4 errors per 250 scripts. That’s just not good enough for me.

Commentors will be kept anonymous on this post.

What a Putz

Posted by The *Angriest* Pharmacist as Drug Companies, Engrish, Government, Insurance Companies, Me being a dick, Politics, Stupid People, True Story, Welfare

Yup…sure would hate to see that…

To be completely honest, while I have my issues with them, Medicare and Medicaid are well-run programs. They allow their money to be spent all helter-skelter, they are the most efficient programs in the entire government. The overhead of CMS is abysmal compared to your other big players like BCBS, Paid, Anthem, and Caremark.

I’m not sure why the post office is always busy. I’m not sure why the DMV is slow as hell — these are subcontracted out anyway, so blaming the government is stupid. It’s like blaming Dr.Reddy’s for having to wait too long for your Glimepiride in my pharmacy.

• индивидуалки долгопрудный

You can see the video or the original comments in its entirety here. In all honesty, it was probably just a slip of the tongue. But, calling someone else stupid and making fun of them makes me feel better about myself…:-) просмотор порно

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There’s a “Kick-Me” Sign on Pharmacy’s Back

Posted by The *Angriest* Pharmacist as Disgusting, Doctors, Drug Companies, Hospital Pharmacy, Insurance Companies, Laws, Me being a dick, Me hating others, Money, Patient Education, Politics, True Story

I guess we’re the flavor of the month as the douchbags and assholes are coming out of the woodwork to take a cheap shot at our lovely profession. A loyal reader, known only as Bond, sent me the link to an article titled, “The Great Drug Switcheroo.” This piece of shit article published by “Prevention Magazine” (which has been around since the 50’s). The tagline is, “Your pharmacist may be changing your medication without your knowledge–and what you don’t know could hurt you. Here’s how to stay safe.”

Once again, the man behind the counter in the white coat is trying to KILL you — not trying to help you achieve optimal results from your drug therapy. It begins with a story of a lady diagnosed with epilepsy who had troubles finding an effective drug regimen. After she had gotten stabilized, she fell of her bike and broke her leg — all because of an evil conniving pharmacist!

Her pharmacists, she learned, had exchanged her Tegretol for a generic that worked a little differently. “Just imagine what could have happened had I been behind the wheel of a car,” she says.

What’s wrong with this sentence besides everything?

The article then goes into THERAPEUTIC substitution and not GENERIC substitution. The article makes the point with statins as well. The problem with this entire bullshit, whacked-out piece of journalism is that therapeutic substitution does not exist outside of the inpatient setting. I cannot think of a situation where that would be legal, and I seriously doubt it is allowed in any state.

For readers not in the know, here’s an example of THERAPEUTIC substitution: I am working a shift at my local hospital. I receive an order for a patient to receive Crestor 10mg at bedtime. The hospital doesn’t carry Crestor because it’s silly expensive. They do, however, carry Lipitor because they have a contract with Pfizer for a good price for it. The Pharmacy and Therapeutics Committee at my hospital did a review and based on their specific protocol, I can swap in Lipitor 20mg for Crestor 10mg as their lipid lowering effects are very similar (based on the results of the CURVES trial). I don’t need the permission of the MD or anyone else as the P&T committee represents the MDs and they have okayed this sub. There are hundreds of places where this happens — IN HOUSE! It does not happen in a pharmacy as Walgreens does not have a P&T committee…:-)

Here’s an example of GENERIC SUBSTITUTION: Your doctor writes for Vicodin 5/500mg. Name brand Vicodin is really expensive, and I don’t carry it. Luckily, he signed the prescription on the side of the blank that says, “Generic Substitute Allowed.” This means the doctor has given me the authority to dispense a generic drug, Hydrocodone/APAP 5/500mg which has been rated AB by the FDA (meaning it is recognized as equivalent therapy by the United States Government).

I’m pretty fucking sure our seizure chick was getting Tegretol or Tegretol XR for some time and the pharmacists switched her over to an AB-RATED generic equivalent. Can we say that this was the cause of a seizure? Fuck no. This bitch has epilepsy. She can have a seizure after a loud fart — did the fart do it? The time frame fits! I just drank a cherry coke. Can we say that Cherry Coke made me a dickhead? No. I’m a dickhead and it’s expected. Anywho, I SERIOUSLY doubt the pharmacist here said, “Well, she’s been getting Tegretol for quite some time. Let’s give her some Phenytoin. It’s okay…I’m a Pharm.D.!” —- No way….They are sensationalizing this and trying to compare dissimilar things.

The article specifically says, “A generic that worked a little bit differently…” — I know it’s semantics here, but generics are the same drug that work in the same way.

The second page of the article talks of a switch done by a mail order pharmacy. This I don’t doubt happens. They know exactly what drugs their plans will cover,  but by the letter of the law, they shouldn’t be making changes. I’d bet they call the MDs and say, “You wrote for Prevacid. We’ll pay for Nexium. Is it okay if we fill the latter?” — Of course the doctor doesn’t care and the patient gets the new drug in the mail without ever being told of the switch. Is that okay? It’s bad customer service as the patient is likely going to be scared and ultimately pissed, but they most likely meet the legal requirements of the law.

Ask your pharmacist to put a blanket statement in your records that you don’t want any medications switched unless you and your doctor approve. “It’s a way of getting your pharmacist’s attention,” says Catizone. “When pharmacists know more, they can do a better job of advocating for patients.”

We’ve all got a few of these assholes in our system. “I want brand name everything! Generics don’t work for me.” It’s these type of assholes that make me lose money on a bottle of name brand Vicodin when 70 tablets expire in a 100 count bottle. But, if they wanna pay for it, that’s fine by me. I’m not gonna lie and put DAW1 — I’m putting DAW2 and you can pay the difference.

Each section in this pissass article says, “If your pharmacist makes an unapproved switch….”  — What’s the need in this statement? Is there really this much distrust in pharmacy and pharmacists? I’m blown away by this. The final section has a quote from Robert Reneker, MD, urgent care physician at Spectrum Health, a hospital system in Grand Rapids, MI. He correctly says that pharmacies are reimbursed better on generics and switches are profitable. He incorrectly states that we are motivated to make these switches by profit.

I, personally, could give a shit less about what prescription a person gets. I’m happy to get the person in the store and make the sale. Volume is volume and it all averages out. If you get name brand something, you do. I’m not going to go out of my way on each of the 800 scripts I fill a day to ensure it is generic and maximize my profit margin. That’s just silly…to think that one would do that. To change you from Nexium to generic Protonix (pantoprazole) requires a call to the MD, the wait, the recount, and the dice roll that your insurance covers it. I may make more money on it, but it’s it worth the 5-10 extra minutes of work? Never…So his claim here is valid, but off base. He also says that pharmacies have told him drugs aren’t on formulary when they are — he’s checked. This is funny to me because I have no idea what’s on anyone’s formulary, and again, I don’t give a damn. If it’s covered it’s covered. If it’s not, I try something else. I have the broad ideas of what’s covered: generics are, Phentermine isn’t, BZDs aren’t on Part D, etc. For fuck’s sake, I could process a prescription and get a rejection that says drug not covered. Then Dr. Reneker calls the insurance company, and they say, “Prevacid? Why sure it’s covered, Dr. Anything you want. Let me send you this form to fill out.”

Dr. Reneker understands that to mean that: The drug is covered. I just got the prescription for my patient. The pharmacist lied to my face. The pharmacist  sees this as: I tried to process it and it was rejected as NDC not covered. The MD called and got a Prior Authorization. Now I can fill it and the patient can pay $75 while Prilosec is 20 bucks for 42 tablets. Way to go, Doc! You think you won, caught a pharmacist in a lie, and got the patient the medicine. The fact of the matter is the insurance company won (twice), you now distrust me and don’t know the whole story, and the patient can’t afford the food anymore that causes her heartburn.

Above is an example of what happens when a journalist talks out of their ass.

I’m not sure who makes the above switches. They are insinuating that you bring in a prescription for Lipitor, your pharmacist is going to send you home with Simvastatin and there’s not a damn thing you can do about it. Well, that’s fucking bullshit. While these substitutions are all fine and dandy, I certainly wouldn’t do them on my own accord. However, Prevention magazine thinks I can and do.

Read REMOVING THE WOOL to see what changes could be made where the new isomer-removed-new-drug/patent-game-type name brands exist and the generic would be cheap to use and work just as well.