Shooting yourself in the foot, 10% at a time.

Something bad happened in California this year.  Something very very bad.  Something so improperly thought out that it could ONLY happen in California.  Something so horrible that it forces you to wonder if the person who came up with this was drunk, stoned, or just an absolute fucking idiot.

I’m of course, talking about the MediCal 10% reimbursement cut.  For those not in the Stupidty State, MediCal is our implementation of Medicaid.

Let me back up to explain some stuff before I go on this rant so those not in pharmacy will understand.

You know when I bitch about getting paid $1.50 over my cost of the medication fee?  Thats called our dispensing fee.  Thats the amount that I make over the cost of the medication that covers my labor, the vials, the power, the tech who fills it, the clerk who has to take your annoying phone call, etc.  I’m hesitant to call it a ‘profit’, because in most cases its not.  It allows us to stay in business.

Now, back to the rant.

Usual reimbursement from MediCal is our drug cost (give or take a few percent to account for wholesaler markups, etc) plus a dispensing fee of a single digit number (less than 10 bucks for those drunk at home).  If I dispense, say, Fukitol, with a ballpark (yet entirely reasonable) price of $200, I can expect to make about $210 bucks.  Those slow out there may be saying “HOLY SHIT, YOU GOT $210 BUCKS FOR THAT PRESCRIPTION! PHARMACY IS A GOLD MINE!”  For those who think this, go work for the State of California, because you are a fucking retard.  Yes, we did get reimbursed by the state a whopping $210 dollars, but unless I can wave a magic wand and make drugs out of thin air, my wholesaler wants $200 out of that $210 so he can pay HIS bills.  So I get $10, which really is fucking good.

So California; despite having Silicon Valley, Google, dot.millionaire companies, San Francisco and LA (that combined pay more taxes in one second than we will all make in a lifetime) is broke.  Go fucking figure.  They decide to whack the MediCal reimbursement for drugs by 10% to stem the bleeding of throwing the baby out with the bath water.  This first was voted into effect on June 1st.  Us pharmacy and medicine peeps said “HOLY SHIT, YOU CANT DO THIS” and did what Americans typically do, tie it up in the courts (read on and you’ll see why).  Well, recently they lost the injunction, so the cuts happened.

Now you may be thinking “gee TAP, 10% cut in your fee isn’t so bad, thats only like a buck”.  Therein lies the problem.  MediCal didn’t cut our dispensing fee, they cut THE WHOLE FUCKING REIMBURSEMENT.

Quick and Dirty:

Drug costs 200 bucks.  We get paid 210 bucks.  Take 10% off of that 210 bucks and you’re left with 190 bucks.  The drug still fucking costs the pharmacy 200 bucks.  We make a whopping -10 dollars.  Thats right, the pharmacy LOSES 10 dollars (in this case) with EACH FUCKING HIGH DOLLAR TRADE NAME FILL.  Throw in some chemo drugs like Xeloda that costs the pharmacy THOUSANDS or HIV drugs at 600 bucks each, and you have yourself a closed pharmacy.

But no, it gets better.  You see, MediCal is in bed with the drug manufacturers.  The drug manufacturers give “kickbacks…er..REBATES” to the state to use THEIR  product.  Why else do you think Nasonex is the ONLY nasal steroid instead of generic Flonase.  Why do you think generic Morphine ER isn’t covered, but BRAND ONLY Kadian is?  The state is getting a rebate for having these on their formulary.

So not only do we lose money on each brand-name prescription, but we are forced to use brand name for certain drug classes.

See how absolutely fucked this is?  So whats a pharmacy to do?

Easy, send the patient somewhere else for brand name drugs.  California Business and Profession code prevents the selling of products for less than what it costs you.  Its part of the anti-predatory pricing laws.

Does this suck for the MediCal patients who need HIV/Actos/Nexium/Kadian/etc? Yup, it sure does.  Our hearts are out to those patients who can’t get their drugs filled, but what other choice do we have?  The chains can absorb the cost for a time until they pull the plug, and the independents cant absorb any of that.

Oh no, it doesn’t stop there.  You know how I said that the cuts were put into law June 1st but got held up in court?  Well they made the cuts retroactive.  Pharmacies are going to get a BILL from MediCal for the 10% difference for EVERY FUCKING PRESCRIPTION they filled since June 1st.

If you are an independent store owner, give money to the Pharmacy Defense Fund (if you haven’t already).  If you’re a district manager for the chains, get your head out of your ass and tell your people to STOP FILLING BRAND NAME DRUGS or you might be out of a job.

I’ll leave you with that.  Don’t send me the bill to cleanup the mess of your head exploding.

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77 Comments

  1. PAS says:

    Let me say this quite simply: Fuck MediCal.

    It is the second most moronic Medicaid program in the entire god damned country. The only one worse is Arizona’s AHCCCS. They managed to beat California only by somehow figuring out how to carve up programs at a level of 200 members each.

    We have two principal programs related to Medi-Cal. Every day we wish fervently for them to die. Their plan documentation is 500 PAGES in an unformatted text file. Each. These files are decades old, drafted up in the 90s by a cut-rate ‘local’ PBM (which financially wrecked itself and was bought up by another company, which was bought by another etc) and has been updated sense by copy-pasting swathes of the document around and scrawling in new nonsensical contradictory rules. These plans absolutely REFUSE to hear any possibility of updating this mess into some sort of modern, coherent readable program.

    The constant set of carve-in-carve-outs of different

    CALPOS is a steaming pile of shit. I have no idea what software they’re running, but from their documentation it looks like it was cobbled together by a bunch of drunk IBM programmers who were frozen in the 1970s. And the entire system is running on a 386 with some taped together serial cables plugged into it.

    One of these programs absolutely refuses to let technicians cancel out any prior auth requests. That includes duplicates (and we get about 3-4 duplicates of most requests), or anything accidentally created. Their forms are illegible, scrunched up messes that are unreadable after being faxed. Every single god damned request has to be sent to one of our pharmacists for review. THEN they have to upload every request to this MediCal plan for them to review – where they refuse to give definite response time (It’s whenever they get around to it), they refuse to give us any email or phone contact info to their program (Just computer drop boxes). To top it off, EVERY SINGLE TIME they approve something it conflicts with ten or more of the unreadable rules in the aforementioned documentation. Which of course, even though they’ve approved it, we’re not allowed to fix without their express god damned permission on every single one.

    Oh, and we’re not allowed to have a formulary. Because we “Don’t need that” to review their PAs. We sit around and have to decipher their buggy, incorrect claim reject messages (Which they ALSO refuse to fix). To top it off for dozens of popular drugs they only cover particular strengths.

    I will take issue with the ‘in bed with’ bit. Medicaid rebates are more along the lines of drug companies strapped to a bondage rack with jumper cables attached to their testicles. Drug companies are required to match the discounts they give to Express Scripts and Medco for Medicaid. On top of that, they’re often coerced into giving much more – since CMS has in the past few years allowed states to collectively bargain for the drugs.

    Ironically, since those rebates are based on what they reimburse to pharmacies on an individual claim level, they’re kinda screwing things up here.

    In conclusion, Medi-Cal is the stupidest god damned Medicaid on the planet, they’re sitting with a loaded shotgun pressed to their own balls. They’ll trash their pharmacy network and screw over everyone and be unable to figure out why it happened.

  2. Dr. Grumpy says:

    Believe me, I understand. It’s similar to the annual tradition of the government playing chicken, with the impending 1/3 Medicare fee cuts that comes up every Decmeber (been fgoing of for roughly 10 years). If they ever go through the public is really going to be pissed to find that half or more of American doctors stop taking new Medicare patients overnight.

    • PAS says:

      What baffles me is that every year people seem to treat the Medicare fee cuts like some sort of shocking, unexpected apocalypse.

      It happens every single year.

  3. JoshTxPharmD says:

    Wow, isn’t that lovely?! Pharmacies have pervasively strict regulation against kickbacks from the drug companies, yet MediCal is doing much the same thing with Californians’ tax money!! How utterly hypocritical! I guess the braindead P and T committee read the bs study (sponsored by the drug company itself) which claimed that Nasonex was superior to generic Flonase and used that to create the formulary. The Californians should be outraged by this blatant WASTE of their precious tax money. I would say they should sue the state for this, but much like your title, TAP, that would also be “shooting (oneself) in the foot,” LOL.

    • Wotan says:

      It gets even better: 3 years ago Medi-Cal officials admitted they had not been very successful (ie – diligent) in collecting the more than 3 billion (yes BILLION) dollars in annual kickback money owed to them by the drug companies. HOW unsuccessful? More than 90 percent of the monies owed had not been collected.

      And nobody gets fired. Nobody loses their job. Nobody goes to jail for gross incompetence and mismanagement of the public trust.

  4. FLgirl says:

    Angry, you were really lucky to see that kind of reimbursement. In Florida, Medicaid reimburses the pharmacy the “MAC—Maximum Allowable Cost” for the drug plus a max 2.50 dispensing fee. The MAC is calculated by First Data Bank. They also receive “reimbursements” from the drug companies for having their medication on the PDL. Now here’s where the waters get choppy. Over the past year, since the state is also going broke, they feel they’ve come up with a “solution” to the problem…moving the patients into HMOs. Granted it seems to be working until the patient realizes hey, I have a copay now? I’m NOT getting the medication for free anymore? and then the sh*t hits the fan. They go back to their doctor who can then write a letter and come up with some eronious B/S as to why the patient shouldn’t be in an HMO. Really? So far though, I’ve only seen the most extreme cases be approved, (i.e. the patient has a seizure disorder, or sickle-cell, or HIV/Hep-B) things of that nature. But fear not! There’s more… Now with Medicaid, they’ve implemented stricter laws the pharmacies must abide by. If the patient is under the age of 13 and is prescribed a psychotropic drug, the doctor as well as the patient’s guardian have to sign a consent form which is basically saying to the state, yes I realize what my doctor just prescribed my kid and no they won’t be held liable if sh*t were to go south. Keep in mind this also excludes anticonvulsants and ADHD meds, everything else goes. The form must accompany the script to the pharmacy where its the PHARMACIES job to keep it on file with the hard-copy for a max of 5 years. But wait! There’s more, all anti-psychotic medications prescibed to patients under the age of 18, are now clinically reviewed by USF Doctors contracted with the state to keep tabs on the overuse of these meds. So say for instance, doctor changes the dose on a 12 year old patients risperidone and the pharmacy calls wanting a dosage change…guess what, they have to call the state, who then will call the pharmacy back with a decision AFTER the USF docs have reviewed the patients file. AND THE HITS JUST KEEP ON COMING, also, HIV/Hep-B patients, if you do not have the diagnosis on file for either, or if it hasn’t been recently billed for by your doctor, guess what? The state has it implemented where the pharmacy gets an AUTO – PA rejection, then calls the help desk, speaks with a clinical pharmacist who puts in a one month override, and is then informed, please get in contact with the doctor to update the patient’s diagnosis. The pharmacy is allowed 2 overrides for each medication to allow the doctor enough time to update the diagnosis. After 2 times, no dice. Now keep in mind, all of this extra sh*t, I mean, guidelines, are in place so if the pharmacy messes up and gets audited, they loose their reimbursement. Pretty sh*tty if you ask me

    NOW that I’ve gotten all that off my chest, just wanted you to know you aren’t alone in the fight against Medicaid, even if we’re on opposite sides of the country

    • Fla Pharmacist says:

      Don’t forget Florida Medicaid is closed most weekends and often takes 3 day weekends if there is a holiday. They were closed for four days for Thanksgiving. This really complicates getting PA’s. At least the medicaid HMOs have people in on weekends. Most also allow for emergency 3 days overrides for meds.

  5. The37kid says:

    The sad part is that in all of this quack-shittery, it ultimately will be the patients that suffer. WFT Cal? No business will sell a product a a loss and continue to offer it in the future. I think we (independents and chain alike) should just hand the prescriptions back to the patients and instruct them to have their physicians order it and tell them why. The physicians have a better organized and influential lobbying group. You always see legislatures coming to an 11th hour deal to protect the MD’s reimbursements, so let’s get them in the fight with us. Unless MD’s want to get into the dispensing/counseling business too (there’s no way in hell they’d have the time to put up the BS from third parties and such that we deal with AND see patients too), they’d have to get our backs on this one. We’re constantly covering their asses and shoulder some of the potential liability too!

    Screw you APhA. Grow a set of balls and unify our profession. Take a page out of the AMA playbook.

  6. Amy says:

    It’s not just Medical, that’s for sure. I’m from Indiana. In 2009 we received a 34% decrease in reimbursement for brand name medications for Medicaid. The next year Medicaid required that all birth control prescriptions be filled with brand name- convenient huh? On July 1, 2011 they issued an EMERENGENCY RULE (where’s the fire?) that decrease our dispensing fee from $4.90 to $3.00- a 38% decrease. After litigation, the pharmacy’s court case was declined and we’re screwed. Before you know it we’ll be PAYING Medicaid to fill their fucking prescriptions.

  7. Whitni says:

    Whats funny is that, at least over here in Georgia, we are not allowed to give medicaid or medicare patients any kind of “points” (ie: gas points) for getting their prescriptions filled at our pharmacy, because the government doesn’t want us bribing them to use our pharmacy. Let me say that again. The government doesn’t want us to bride patients on medicaid or medicare to use our pharmacy. WHY WOULD WE EVEN?? Oh yes please, will you please use our pharmacy even though you haven’t showered in a week and the clothes you have on could have belonged to Jesus himself 2000 years ago and by the way you are poor not homeless so at least take a shower, and you yell at me because the .50 prescription was supposed to be FREE because everything you get is supposed to be FREE FREE FREE because you don’t get to have a shitty job like I do??? Yes, please come to our pharmacy, I’ll give you gas points under the table.

    • Disabled and hate it. says:

      Come on, people with mental disabilities often can’t take care of them selves. This includes taking showers regularly. It’s not our fault.

  8. I_hatemyjob says:

    I like to switch all brand meds to generic. But we all know Medi-Cal is very rich and know how to spend taxpayers’ money, Medi-Cal prefers brand name to generic, just an example Lasix over Furosemid, not to mention all birth control pill. 99% of Medi-Cal recipients come into phamracy with the mentality that they deserve to use all taxpayers’ money to get brand name meds. How many times did you hear a Medi-Cal recipients said “I want brand name only and MY INSURANCE WILL COVER BRAND NAME”. The system need to be changed not just cut its reimbursement but change its formular to “generic only”. I am sure it will save a lot of money.

    • We would flat out refuse to despense brand name Lasix. That is some Bullsh*t! One thing to get something for noting but it is another to milk it for everthing it has.

      • Disabled and hate it. says:

        Again, a lot of these people suffer from mental and other disabilities, it’s not getting something for nothing. Think about the suffering these people have to go through just to get on these programs.

      • Disabled and hate it. says:

        On top of that, until I started reading this blog, I had no idea that dispensing fees were so small, and you were losing money on dispensing these brand name drugs, at least in California. If I was told I could get brand name medications, I would do it too. I find they don’t do a better job than the generics, but they do seem to have coatings which help me swallow things like prednisone where the generics I usually vomit back up because of the unbearable taste. Same with Xanax, the generics are so bitter I gag on them even with large amounts of water. However, if I knew pharmacies were being screwed out of their dispensing fees and losing money, I would never ask for a brand name, I would deal with difficulty knowing my pharmacist and pharmacy can stay open and support their families. Maybe you could post a sign or something stating you will fill generics on these programs but cannot fill Brand names except for the ones that the state won’t allow this, and I bet a lot of people would be okay with the generics knowing their favorite pharmacy is going to still be around if they do.

    • Jeff says:

      In many cases Medi-Cal requires brand name and WILL NOT pay for generics. Cozaar, Kadian, Diflucan, Biaxin, and Topamax are all available generically, but Medi-Cal requires brand name so they can get their rebate. Between the giant rebates and the federal matching funds, these brand name drugs are actually money makers for the state.

      • I_hatemyjob says:

        Besides the kick back ths state government received from brand name pharma companies. There is am important factor why MediCal only reimbursed brand name. Our government has a big heart, it does not want any MediCal recipient to feel inferior to any one working for living. Since general public can request brand name only medication why should mediCal recipinet be an exception. Therefore MediCal take our tax money and spend it generously. I always wonder what if no one pays tax can MediCal still afford to reimburse brand name only policy???

  9. CaliRX says:

    What TAP forgot to mention about the rebates that MediCal recieves for having branded products, don’t even go back into the MediCal fund, they go back into the State’s General Fund. How effed up is that, not only are we pharmacies losing our arse dispensing branded product to these “rotten croch fruit”, but now we’re financing all these elaborate pay raises the state keeps passing for it’s employees and their fancy litte parties. It’s horse shit. The only good thing comming of this is that the defense fund is a gonglomerate of hospital, doctor, long term care, and pharmacy organizations to show a united front against these cuts.

    • PAS says:

      This may be a state based thing. It seems like something California would do.

      In the state I work most with, the state’s P&T meets every 90 days and requests an analysis from us at their PBM of the drugs they’re going to be reviewing. This basically consists of a packet detailing each drug within that class, a brief summary of any major issues or clinical concern, along with current pricing information, usage and estimated rebates back to the Medicaid fund.

      As near as I can tell, all Medicaid rebates for this state are sent directly back into the fund, and principally allocated towards pharmacy costs. This isn’t exclusively the case, as we recently did a little tinkering with some of the supplemental ones, and managed to scrape together enough to cancel a 9% flat cut to all medical reimbursements. On a program of one million plus people, that’s not a small bit of cash.

      One thing I’ve noticed, is that states that tend towards monolithic Medicaid programs tend to have consistently better, less problematic programs. Generally, what seems to work best is a single PBM, contracted for services ONLY, and a limited number of HMOs (or FFS only), all of which are required to provide similar, consistent programs.

      But this is California we’re talking about

  10. Kansas got cut too. We get MAC’d on everything. Cannot appeal. Generics that a year ago were just pennies have went up 10x in price. Things are getting out of hand.

  11. Kennyc says:

    Here is RI it is a little different. 95% of all Medicaid patients are placed in HMO manger care plans. The plans are given a formulary from the state. No brands of any kind are covered without pa (even if their is mo generic for that med) (expect for drugs like plavix where this is no good alternative that saves
    Oney brand or generic) Even some strengths of generic medications (depending on cost differences) are not covered. If a patient gets a pa but is non adherenent (late refill or no evidence of benefit) pa is revoked after 3 months.

    There are no vacation overrides allowed (if you can afford a vacation pay for your own meds). Any the biggest HMO is now locking patients into 1 pharmacy (the patient chooses and can only change if they have a good reason like a move) to prevent doctor/pharmacy shopping. It was a pain when the program first started, but now it is saving the state millions.

    • samskeyti says:

      yeah, here in RI, medicaid isn’t that rough, but in massachusetts, MH is a pain in the ass, and they change their guidelines every six months. ><

  12. Robert McCarron says:

    I am a physician in Florida (originally from N.J.) and have always had excellent raport with my pharmacaist colligues. I had NO idea you guys are under the same stress and BS we physicians have been under for a number of years. I’m very sorry to hear about your troubles and agree with all that you have said. I don’t remember who told me this (it’s been many years) but it went something like…..Don’t make complaints, give solutions! I am wondering if anyone has a credible, nonemotional approach to fixing the problems. Yes, your highly accurate and angry descriptions of moronic patients and corrupt governmental processes are funny yet tragic… can we approach this with a rational proposal? I am at wits end and have thrown up my hands a long time ago but do hope some enlightened sole out there has an approach. We cannot rely on our corrupted and politically- aligned professional organizations (i.e. AMA= WORTHLESS, TOOTHLESS, CORRUPTED).I have long felt that a national “sick-out” was in order but everytime I put it in writting for placement on the “Medical Blog Sites” it is never presented…..so I guess the medical blog sites are also in collusion with the governmento-pharmaco complex. Thank goodness for The Angry Pharmacist…it looks like a great sounding board. Thanks for listening and please try to find out what we can do to unify the disciplines in an attempt to bring about constructive changes in a totlly broken system.

    • grumpyrph says:

      Good point, Dr MC, but difficult to accomplish. I have worked with city and county officials to help reduce prescriptions costs. They just don’t understand. The city/county electees have staff that handle medical needs of employees and indigent citizens. This staff hires outside consultants paid by the city/county to make these decisions. The consultants make money on both sides of the table ie. they are paid by the hiring party and also get something from the PBM they recommend. We had an oppertunity to change a formulary to cover generic Protonix to replace the Nexium (who’s rebate contract had expired) saving the local program over 100K per month. It took 3 months to get the meeting at which we were told to continue doing the good job we were doing, but it would would cause too much turmoil within the hospital staff to make the change smoothly. Govermemt employees envolved in the decisions do not have a clue about the costs or profit margin on any prescription. Sure, they could have had cuts saving them and overall 10% without creating a class of high priced medicines that result in a loss for the pharmacy, but it would require work – something they are not accustomed to doing. I had to refuse service to a patient we have had for 20 years (HIV,COPD), because I would be losing over $750 a month on his prescriptions (we were only making $100 over the $8000 cost of medicine previouly). It is just not right.

  13. I was told by a RPH within Indiana Medicaid years ago – Amy you may know him.. he has been around there forever .. that Medicaid would not even consider discussing pharmacy fees until patients start complaining about not being able to obtain services. In their mind.. as long as there are providers providing services to the majority… they must be making a profit and if they are making a profit… the reimbursement from the state is still probably too high…remember… the states don’t have the word PROFIT in their vocabulary.

  14. Cali Tech says:

    I am so tired of the ungrateful Medi-Cal “patients” (I HATE calling them that) who act as if they are entitled to get their meds for “free”. These jackasses need to understand that WE taxpayers are the ones buying their crap that certainly isn’t “free”. All people on Medi-Cal should be forced to take only the cheapest generic medications. And those of us who work in California know that we need to completely do away with the TAR system! Fuck TARs!!! No, i’m not going to do a TAR so your fat ass can get Alli OTC, stop eating fucking cheeseburgers (purchased with food stamps), and eat a fucking salad (NOT purchased with food stamps). All these freeloading, scumbag, entitled, leeches of society need to drop fucking dead so that the rest of us fine & decent people can continue on living a happier life without them. God bless America!!! :)

    • mccarron says:

      WOW…GREAT STUFF

    • Wotan says:

      Hey Cali-Tech, being a Tech, you may not be aware that CPhA (California Pharmacists Assoc.) elected a guy named George Pennebaker as CPhA President about 5 years ago.

      George is credited (and brags about) being THE GUY who invented the TAR.

      Years ago, when the state was having their usual budget probs, George told them HIS COLLEAGUES would gladly take the (unpaid) time to fill out these forms and make this TAR thing work (MD’s had already flatly refused to participate in any such unpaid labor).

      I once had the chance to talk to him personally, over a TAR problem, when he was still their point man. I told him that the state needed to either cover EVERYTHING, and enforce copays to limit overusage, or get serious about their formulary — allowing no exceptions.

      He said that wouldn’t work, too many people’s needs would be unmet. I told him that 99.999% of legitimate needs would be met without using TAR’s, and that the entire TAR system should be trashed (at the time I didn’t know he was the INVENTOR of the damn thing!).

      When I saw he’d been elected CPhA President, I couldn’t believe it. I hadn’t voted, since I could care less (I thought) who would take on such a worthless job. I had no idea they’d elect the antichrist of Pharmacy — the architect of the TAR.

      Since then, I haven’t renewed my CPhA membership. They obviously have NO CLUE what’s really going on in the trenches. I could cite much more of CPhA cluelessness.

      So next time you do a TAR, thank George! He’s looking out for us!

      • rph3664 says:

        What’s a TAR?

        • Cali Friend says:

          T.A.R. = Treatment Authorization Request.
          Pharmacy fills form with complete info of Pharmacy, Patient, Doctor, Medication, Strength, Sig, Quantity, Reason for Medication. Then, fax it to doctor, doctor would sign then doctor would fax to State of California. Then, wait….then try re-billing daily…Pharmacy staff spends a lot of time on this. I heard of Electronic T.A.R. request. I had to hand write and manually fax papers and papers and papers…I hope my help went to patient that TRULY NEEDS the med.

  15. I_hatemyjob says:

    There are two things that can easily be changed. The first one is to change formulary to “generic only”, the second one is to allow dispensing pharmacists to change medication when MediCal is not covered. To me MediCal prior authorization is a joke, look at this way, I am paying for MediCal through my tax why would I approve any medication that can be substituted for cheaper one. Techically WE are the owners of MediCal, we should be able to change everything right at the spot, therefore no “prior authorization” for MediCal from now on, this is no need to hire a clinical pharmacist(sorry my colleagues) at MediCal to execute this.

  16. Aa-chan says:

    Texas CPhT chainworker, here. I hear ya.

    In Texas, things are about the same. We’re all flabbergasted that Medicaid will pay for Nasonex, but not fluticasone, or for brand Depakote, but not divalproex. Or — what really gets us — BRAND Adderall XR and Concerta instead of the damn generics. Then, there’s the TXVDP website, where we get to spend hours on end looking for things that Medicaid will cover, because, when we call their phone lines, they can take up to an hour to answer (and they close at 4:30 PM CST).

    It’s… a mess.

    Thanks for the insight, TAP. You rock!

    • PAS says:

      Nasonex has some serious rebate BS going on. The three major medicaid, or partial medicaid programs I deal with all stripped it off their formularies and required step therapy with generic fluticasone, flunisolide, or Nasacort AQ (with a copay and limitations). In nearly every case I’ve seen, providers gleefully substitute them once they realize they’re covered. The only exception is one fellow who regularly prescribes all his nasal steroids at 2-3x the FDA approved doses.

      Adderall XR is worth noting because the drug is mired in bullshit, and a series of protracted decade long battles in the courtroom. The principal antagonists being Teva and the brand owner Shire. Several other companies have tried to release generics and gotten sorely spanked. The most recent legal settlement I’ve seen involves letting Teva resell a portion of Shire’s capsules with the brand name taken off the side. In the technical lingo, this makes it a Multisource Code M drug, as opposed to a generic – it doesn’t have its own ANDA. Medicaid plans, as a rule, avoid drugs in this situation like the plague. Most exclusively cover the Shire labeled product. One of our programs is covering the brand name as the generic, covering it with no copay and paying its higher ($3.00/rx) dispensing fee. One program stopped covering Adderall XR at all unless it’s appealed directly to the state.

      Many programs were burned badly by a similar situation with Protonix, and pricing games by Wyeth in the past few years.

      But again, rebates complicate the system. The drug companies hate them and need them at the same time, but those rebates are in many cases the key to keeping a program running without drastically cutting eligibility

  17. Farm.D says:

    Wow this is great news for Washington State lawmakers! Now our wondrous state is only 49th out of the 50 states in regards to pharmacy reimbursement. Currently we are at AWP-50% (yeah that’s right, 50 percent) on generics and AWP-14% on brand name medications with only a $4 dispensing fee, CA gets $7.25. The lawmakers here just don’t get it, along with the shit reimbursement we are one of a handful of states that doesnt make their patients pay a small copay for their medicines. I think you can see where this is going…. Stubbed you toe tripping over your unused workboots? Hit up the ER for 8 Vicodin! Sure youre out about 6 hours of your important time, and made people with real emergencies wait longer, BUT IT DIDN’T COST YOU A DIME! You would be shocked how many ER scripts I see for OTC items, not covered in your state? Have your patients move to Washington state, everything is “free” here, even hydrocortisone 1% cream, Dr Scholl’s wart remover, Trojan Magnums (no Rx needed!), and pedialyte! Want to see how your state stacks up? These figures are from 6/2008
    http://www.cms.gov/Reimbursement/Downloads/StateRxReimbursementJune2008.pdf

    • radrone 5316 says:

      At SUNY schools you don’t even have to have Medicaid; you get all otc’s for free; just for being a student who pays ridiculously low tuition in the first place. We have “shopping Friday” here, where all the suitcase students come on in to the Health Center while on the phone with their parents, who are dictating the shopping list for their home bathroom medicine cabinets………..and our Governor has just issued a 9 day pay furlough for this academic year for 75% of the employees…………..wake me when it’s over

  18. MSPharmD says:

    This is absolutely outrageous, and unfortunately it has been happening for a while. Reimbursement rates have been cut many times. Physicians and pharmacist are suffering. We are all in the same sinking boat and our government just doesn’t get it.

    We need to unify the effort to send a strong message to the Medicaid/Medicare administrations, let them know that the cuts are not accepted by the health care professionals.

    I also believe that we need t get patients on board with us, I am sure that we all have some sort of communication window with our medical patients that has been coming to our pharmacies for some time and who like to keep doing so. Most of the time patients have no idea that we are loosing money on brand name meds, or that we barely surviving with such low reimbursements. All they know that the drug is $ 300 cash price and we are making tons of money on it, but they have no idea that we are actually loosing money just to provide them service.

    Have the patient complain to their medical office, or to their congressmen and senators. Let them know that we cannot keep loosing money for much longer and eventually they will have to be refused service and/or care. Just like what many physicians are doing and refusing to take any new medical patients; pharmacies will eventually refuse to take medical patients as well.

    • I_hatemyjob says:

      Dear MSPharmD. Do you think they will complain to their medical office or public officials for us?? No, they will only complain for themselves. I am sure you had such an experience before. When you told MediCal patient her/his medication was not covered. The first reaction from them was “No, it should be covered”. A few minutes later, you would receive a phone call from MediCal wanted to tell you such and such was covered. And then you processed again, amazingly it went through. MediCal recipients are a group of free loaders all they want is free medication. They do not care pharmacy is not making any money. My biggest question is for a person that can not even speak a word of English but he/she has MediCal???? What a great country.

  19. grumpyrph says:

    I don’t often do it, but kudoos to Walgreens for not signing Express Scripts new contract. I just hope the independents have as much guts to tell them to stick their 40 cent despencing fee up their ass. If the Govt. lets Express by Medco, we will have to pay them to fill prescriptions. These PMB are working the manufacturers just the way they work us, but at least the drug makers have the ability to figure the rebates into their price ie a drug that should cost $150 is marketed at $250 to cover the rebate given to the PBM. That’s why drug are less expensive in other countries. Does anyone know how much the insured group gets in rebate savings. I’m betting they are luckey to get $10 of the $100 savings.

  20. kmg says:

    Dude, seriously….all of this bitching makes you all sound terrible. The world is tough everywhere… wake up! As a teacher, my salary takes up only the first 5 digits of your salary, and cuts keep a coming. Our school district is on the verge of closing down. While I agree that this MedCal idea sounds terrible, you all sound like a bunch of spoiled brats.

    • Doh says:

      KMG, I’m sure you were well aware that your teaching salary was 5 digits when you started with so don’t compare apples to oranges. And FYI, not all RPh’s make 6 digits. And even if we all made $100,000, I highly doubt that your salary is 10K so get off your high horse. Also, how many years of schooling did you receive before becoming a teacher? How much $$ in loans did you rack up? Let’s see if you change your tune if you have a $200K debt and will be forced to close down your independent pharmacy because of this ridiculous work for free!

      • MTG says:

        Don’t forget the pension and continued health benefits aster retiring at 55.

        • Realistically Speaking says:

          Don’t forget the “apples and oranges” game. Teachers like to point out how they only make $$$$$ per year. Uh, actually they make that figure working only 9 MONTHS, no nights, no weekends, no holidays.

      • Cali Friend says:

        In my quick math, a pharmacist actually makes only $80000 a year.

        My calculation involves:

        Most pharmacy schools now require Bachelor’s Degree. After earning Bachelor’s Degree, she or he could make about $40,000 a year.

        If she or he continues to make $40,000 a year for 30 years, total earning will be $1,200,000 with ZERO EXPENSES of PHARMACY SCHOOL.

        For this new PHARMACY PATH, let’s see the losses and earnings:

        Loss #1: For not working, FUTURE Pharmacist loses $120,000 for 3 years of pre-pharmacy classes.

        Loss #2: For not working, FUTURE Pharmacist loses $160,000 for 4 years of PHARMACY SCHOOL.

        Loss #3: For tuition, FUTURE Pharmacist loses $160,000 for 4 years of PHARMACY SCHOOL.

        Loss #4: For INTEREST of STUDENT LOAN, At the end of 30 years, Pharmacist loses $120,000 (Yep, the PRINCIPAL OF $160,000, at rate of about 8%, lasting 15 years would cost $120,000 of INTEREST FEE, with monthly payment of about $2000).

        Total Expenses for PHARMACY CAREER: $560,000.
        Total Earning: $100,000 a year for 30 years = $3,000,000.

        Net Earning: $2,440,000 in 30 years.
        Average earning a year: about $80,000 Before Tax) (after taxed, net income would be less because tax is based on $100,000).

        At the end of 30 years, the pharmacist will sit down and add all money made and lost for the PHARMACY CAREER, the pharmacist would find out that: pharmacist was actually only making $80,000 a year.

        Background: Bachelor’s of Science in Marketing and Doctor of Pharmacy.

        (And I am did not subtract all the extra costs for 3 years of pre-pharmacy classes, moving to another state, paying rent 3 years when I alread had a house, the SEVERE STRESS FOR 3 YEARS of knowing: 1 of 5 Pharmacy Students was kicked out of my Pharmacy School for not passing the school test….)

        I am thankful for all that to be done. Now, as a licensed pharmacist, I can help the world…

        Please also remember as well, during pharmacy school, I paid $40,000 a year to do ROTATION, a fancy name for “2500 hours of FREE WORK” at pharmacies (to learn pharmacy experience so I can serve our community).

        Now, you see how much a pharmacist really makes.

    • altux says:

      well, if you must pay to teach not the other way (you are paid TO teach), won’t you be angry? it doesn’t take a very bright brain to tell somethings wrong if you must pay to do your job, not be paid to do a job. do you understand?

  21. got the oc's? says:

    Pulled from craigslist in Las Vegas, NV Proudly dispensing enough hydrocodone for every man,woman, & child in the state. Advice from an ER doctor to drug seekers

    Date: 2007-03-27, 9:56AM PDT

    OK, I am not going to lecture you about the dangers of narcotic pain medicines. We both know how addictive they are: you because you know how it feels when you don’t have your vicodin, me because I’ve seen many many many people just like you. However, there are a few things I can tell you that would make us both much happier. By following a few simple rules our little clinical transaction can go more smoothly and we’ll both be happier because you get out of the ER quicker.

    The first rule is be nice to the nurses. They are underpaid, overworked, and have a lot more influence over your stay in the ER than you think. When you are tempted to treat them like shit because they are not the ones who write the rx, remember: I might write for you to get a shot of 2mg of dilaudid, but your behavior toward the nurses determines what percent of that dilaudid is squirted onto the floor before you get your shot.

    The second rule is pick a simple, non-dangerous, (non-verifiable) painful condition which doesn’t require me to do a four thousand dollar work-up in order to get you out of the ER. If you tell me that you headache started suddenly and is the ‘worst headache of your life’ you will either end up with a spinal tap or signing out against medical advice without an rx for pain medicine. The parts of the story that you think make you sound pitiful and worthy of extra narcotics make me worry that you have a bleeding aneurysm. And while I am 99% sure its not, I’m not willing to lay my license and my families future on the line for your ass. I also don’t want to miss the poor bastard who really has a bleed, so everyone with that history gets a needle in the back. Just stick to a history of your ‘typical pain that is totally the same as I usually get’ and we will both be much happier.

    The third rule (related to #2) is never rate your pain a 10/10. 10/10 means the worst pain you could possibly imagine. I’ve seen people in a 10/10 pain and you sitting there playing tetris on your cell phone are not in 10/10 pain. 10/10 pain is an open fracture dangling in the wind, a 50% body surface deep partial thickness burn, or the pain of a real cerebral aneurysm. Even when I passed a kidney stone, the worst pain I had was probably a 7. And that was when I was projectile vomiting and crying for my mother. So stick with a nice 7 or even an 8. That means to me you are hurting by you might not be lying. (See below.)

    The fourth rule is never ever ever lie to me about who you are or your history. If you come to the ER and give us a fake name so we can’t get your old records I will assume you are a worse douchetard than you really are. More importantly though it will really really piss me the fuck off. Pissing off the guy who writes the rx you want does not work to your advantage.

    The fifth rule is don’t assume I am an idiot. I went to medical school. That is certainly no guarantee that I am a rocket scientist I know (hell, I went to school with a few people who were a couple of french fries short of a happy meal.) However, I also got an ER residency spot which means I was in the top quarter or so of my class. This means it is a fair guess I am a reasonably smart guy. So if I read your triage note and 1) you list allergies to every non-narcotic pain medicine ever made, 2) you have a history of migraines, fibromyalgia, and lumbar disk disease, and 3) your doctor is on vacation, only has clinic on alternate Tuesdays, or is dead, I am smart enough to read that as: you are scamming for some vicodin. That in and of itself won’t necessarily mean you don’t get any pain medicine. Hell, the fucktards who list and allergy to tylenol but who can take vicodin (which contains tylenol) are at least good for a few laughs at the nurses station. However, if you give that history everyone in the ER from me to the guy who mops the floor will know you are a lying douchetard who is scamming for vicodin. (See rule # 4 about lying.)

    The sixth and final rule is wait your fucking turn. If the nurse triages you to the waiting room but brings patients who arrived after you back to be treated first, that is because this is an EMERGENCY room and they are sicker than you are. You getting a fix of vicodin is not more important than the 6 year old with a severe asthma attack. Telling the nurse at triage that now your migraine is giving you chest pain since you have been sitting a half hour in the waiting area to try to force her into taking you back sooner is a recipe for making all of us hate you. Even if you end up coming back immediately, I will make it my mission that night to torment you. You will not get the pain medicine you want under any circumstances. And I firmly believe that if you manipulate your way to the back and make a 19 year old young woman with an ectopic pregnancy that might kill her in a few hours wait even a moment longer to be seen, I should be able to piss in a glass and make you drink it before you leave the ER.

    So if you keep these few simple rules in mind, our interaction will go much more smoothly. I don’t really give a shit if I give 20 vicodins to a drug-seeker. Before I was burnt out in the ER I was a hippy and I would honestly rather give that to ten of you guys than make one person in real pain (unrelated to withdrawal) suffer. However, if you insist on waving a flourescent orange flag that says ‘I am a drug seeker’ and pissing me and the nurses off with your behavior, I am less likely to give you that rx. You don’t want that. I don’t want that. So lets keep this simple, easy, and we’ll all be much happier.

    Sincerely,
    Your friendly neighborhood ER doctor

    it’s NOT ok to contact this poster with services or other commercial interests
    PostingID: 301345524

  22. rph3664 says:

    I’m okay with Trojans being paid for. Getting people to actually use them is somewhat more problematic.

    And I’m guessing that Medicaid will cover Zohydro, the new extended-release hydrocodone, in unlimited quantities with no questions asked.

  23. Thats OK I am one of the lucky ones in my state, I lost my providership status for a year and had to pay back a quarter of a mill in overpayments..I thought I got screwed, but I would not go back to medicaid even if they offered me back the money I had t repay them..They are doing the same thing here in NY. Taking 1 or 2 % off the top, going retro on overpayments because we made a few extra dollars (how dare we). Over 200 pharmacies had to close during the past year in NY. I understand the problem of fraud but they’ve taken it to a whole new level and in doing so hurt a lot of GOOD guys out there. Bottom line is they just suck and they could care less about the fallout they incur.

  24. Pharmacist Bob says:

    Aren’t chain companies predatory also? They rape the wallet of the consumer every way possible! Chain companies cannot function without the licensed pharmacists yet the pharmacists are treated less than professional by stretching every non-professional money making metric imaginable! Chain companies need to be stifled; pharmacist need to act, how many stores owned by one company is too many? Chain companies will be the death of our profession; we need one strong pharmacist organization, and stop the school mills.

  25. I_hatemyjob says:

    Today, we have a prescription that makes me realize why CA always has budget issue. This is a 13 years old male who is classified by one of the big medical center in SoCal as “malnutrition”. I was told that the kid had no underlying illness but his growth curve was at only 25th percentile of his age. Both parents have a job in health profession. Now the interesting thing is coming, because of this so called malnutrition he is receiving ensure from CCS, another word we are paying for his ensure. My question is the kid is coming from middle class family, parents have a good job how can “malnutrition” was dignosed by a RD from a well known medical center. Can someone help to understand????????? Do not get me wrong, if any family can not put food on the table of course the government needs to help. But this kid is coming from good family why does CCS even agree to pay for his ensure????

  26. bcmigal says:

    “Less then professional” is much too kind. The overlords are disrespectful and abusive. They never miss a chance to demoralize and dehumanize us. I would say that pharmacy as a medical profession is dying if not already dead.

  27. angryintern says:

    In light of recent events, angry pharmacist should rant about how express scripts and walgreens can go die in a fire. :D

  28. Fran says:

    When Medicaid, education and airlines are deregulated by the Fed’s, then good old capitalism comes into play.
    Teachers in MI have lost pay, benefits, and rights. MI wanted to control Medicaid because they thought they could do a better job at the State level. MI automatically enrolls Medicaid clients into an HMO, unless they have Medicare.
    All medications are generic, unless the physician can document a need for an exception. Michigan appears to have a very low filling fee. There are very limited number of Dr’s that will treat Medicaid patients. These unscrupulous Dr’s will write a prescription for anything, including marijuana. There is a large segment of the population that will use drugs and alcohol, no matter what the consequences. This same group abuse or neglect their children. They abuse their children’s prescriptions.
    Many of these children are born with developmental disabilities that are draining the Medicaid system.
    This is catch-22 system that perpetuates itself.
    Regarding chain pharmacies: how could Walgreen, Rite Aid, Walmart expand to every corner in the US and Puetro Rico without some type of profit? It’s not on the milk.

  29. Kaitlynn says:

    I thought of this blog today after I almost lost it callling an insurance company. I am a pharmacy tech for an independent/compounding pharmacy. I was trying to get a script thru for a patients routine morphine fill. I got the rejection “M/I prescriber ID” I was confused because it is a doctor we use all the time, we have every number in her file, the pharmacist I work with is related to her. Lol so, I figured I must be going crazy from all the ins bs I have been dealing with since the new year started. I rechecked her numbers and then called the Ins. I got someone who i could hardly understand… No, not because she was foreign… But because she was mumbling her routine spiel because she could give a damn. She then proceeded to explain to me that I needed to call the doctor and verify that she is indeed certified to prescribe controlled medications. Then, once verified, I could use an override code to submit it through the insurance, however if I overrode it without verifying the pharmacy could be subject to paying the fee of the medication (another thing to need to document/another thing to be audited) …………………….. I was silent for a moment. What the fuck do we have a DEA number for?! I professionally repeated this back to this woman… And then I snapped… I cut her off… Told her it was just another way for the insurance companies to steal money…. And hung up. I know this person isnt personally responsible for this… And I became another asshole in her day…but I reached my breaking point. It matters to me that my pharmacy stay in business. I like working and paying my bills! I made the note on the rx, used the damn code, and then realized at the end that we we were being paid below cost. So, now I have to tell my boss/owner/pharmacist what I’ve been doing the past 10 minutes…so he can reach HIS breaking point and further fuck up the day. I was greeted in the morning with a “welcome to hell”… Yeah… Hell is about right. I ended the day with an aggressive old man invading my personal space, in my face because he doesn’t understand what a deductible is. I just love abusive assholes yelling in my face, “is it the insurance that’s the problem or the PHARMACY?!” anyway… Keep writing… At least I know I’m not the only one!

  30. How long have pharmacists been bitching about reimbursement rates? In all of that time how often have those rates increased? Right, zero.

    Face the fact that the profession has brought third party control upon themselves long ago and that it’s too late to do anything about it now. First the independents will vanish, then the chains will continue to merge until there’s only one left standing. Only then may change occur.

  31. Pharmacist Bob says:

    Bingo Mr. Cynical! Now you see the evolution of this mess our profession is in. If you merge with a PBM the DNA has mutated in the right direction for survival of the fittest? Unfortunately the winner is a for profit driven mega monster almost a monopoly company, and what impact will our profession expect from that result? Profit driven chain companies need to respect our profession when you consider the fact that they cannot operate without the licensed pharmacists! So, I think we better get some action to fight the potential demise of our profession!

  32. CollectiveCognizance says:

    Hey, TAP, if you ever decide to hang up your pharmacist’s coat you really should have your own TV show — an Andy Rooney-type format.
    You’d also be a great teacher, if an unconventional one. We could use more of those.
    Thanks for an informative -and always spicy- blog!

  33. Carolyn... says:

    Yeah, here in Ontario an ODB patient gets us a $7.00 dispensing fee, and the patient has a co-pay of $2 or $6.11… A regular cash/drug plan patient gets us $11.99 plus mark-up… Other pharmacies may have different dispensing fees, but I think the lowest I’ve seen it is about $8 to $9…

  34. AlmostThere says:

    I’m a tech at a large chain pharmacy. We have a great deal of Medicaid pts due to the location of our store. I get frustrated when I see 3 and 4 year old children getting an rx for ADHD meds. I get angry when a hard working parent has a high deductible and pays $500+ for an Abilify rx and then a Medicaid pt comes in and bitches that they have a $3 copay. Their cigarettes cost more than the prescription! But of course, there is no hesitation in buying those or mountain dew.

    Will this crap ever change? I try not to be bitter but I am! Just because people have child after child they get free money, free food, free healthcare, free or next to nothing rent.

    Of course my state has switched everyone back to their original insurance so CareSource is health and rx, Medicaid is health and rx, etc. instead of Medicaid being the rx umbrella.

  35. bcmigal says:

    Where are you, TAP??? We miss you!!!

  36. Mathew says:

    Pharmacy is exempt from this draconian reduction. Check out 12/22/2011 news on medi-cal website.
    In any case, the amount of BS they put us through is not worth the buck to fill a patient. What’s it like in non-retail setting for medicaid payments. Would love to know.

    Thanks,
    Mathew B

  37. John says:

    When are you guys going to get it? I have been in this field for 16 years and I constantly see these posts of whats wrong with the industry, how we are being screwed, and how we should come together and make a stance.

    Sorry. It hit me the other night that this profession is already controlled and you have no say in what will happen next. The hopeful dreams of bonding together is rediculous. You are forgetting the magnitude of the hands of the retailers and thier movemenmt into each board of pharmacy.

    Any profession that constantly hopes for change is a profession destined for no change. No MD or dentist has to worry about this.

    This profession is controlled. Sorry. No change with coming together and crying about change.

    You are screwed and so is the profession. Get out or do it.

    It is aweful.

  38. Jeff says:

    Or the fact that most teachers only work part-time (less than eight hours/day) for only 9 months out of the year and get the entire summer and every holiday off. Pharmacists would only make 5 figures if they only worked part time for 9 months out of the year, and then took the rest of the year off. According to salary.com, median elementary school teach salary in U.S. = $52,000. Let’s assume the average teacher works about 6 hours/day (I know, most schools are in session from 8-3, but most teachers also get a “prep period” at some point during the day). So that is 75% of how many hours a typical full-time employee works. Anyone else that made the same hourly rate, working full-time would earn about $69,000 in the nine months that school is in session. Now, if that same person worked for 12 months/year instead of 9 months/year, they would bring home $92,000/year.

  39. eyzonla says:

    HA ! Just ran a prescription through on Medi-Cal for Nexium 40mg #90 and had the nerve to get reimbursed $522.04 and my cost is $533.28 = a $11.24 loss EACH time I fill that ! Yeah, right… You know that prescription was reversed and given right back to the patient. Let’s just take a low number- Just imagine if I do 15 or 20 prescriptions like that every day (not even mentioning the other losses from other PBMs,etc)? Just do the math… I may as well close shop. It’s rediculous ! What other profession is constantly asked/forced doing things at a loss(paid less than the cost) ? Lotta nerve !!!

    • retail sucks says:

      I do this with discount cards, I’m still waiting for my testicles to drop to start doing this with insurance. This might be the retail trenches only recourse against our dumbass corporate. Since I dont give a shit whether my chain makes money or loses money (kinda like they dont give a shit about doing what’s right), my biggest incentive to do this would be to create less work for myself, which is actually a really big incentive. Two things wrong with this though; #1. I believe some chains dont allow the trenches to see reimbursement data, and #2. the chains that do allow the trenches to see reimbursement data will stop or write a brain-dead policy prohibiting fill such RXs.

  40. Andrew A. Gill says:

    You may be pleased to know that the only reason I would second guess my doctor’s opinion on generics is if he suggested that I had to use that brand name version. Seriously, I’ll take generics over name brand 10 out of 10 times; nothing pisses me off more than a company making a small fortune by ripping people off for something in the public domain.

  41. Glenna says:

    When I get the “Is it free?’ question from the medicaid ilk I say no. After a pause for “the look” on their face, I say, “The medication is not free, there is just no charge to YOU”. Try, it sometime, it confuses the hell out of them…

  42. John says:

    Band together with other pharnacies and go Galt.

  43. James says:

    WOW! It really is happening. If you think this is bad, just wait a year or two. Things are going to get really fucked up. I haven’t even gaduated school and I’m already thinking of another career.

  44. John the Eye Doc says:

    I wish every bleeding heart, tree-hugging, liberal politican would be forced to spend 1 day in a medical office on welfare day and one day in a pharmacy to see what is really going on. I think it would be an eye-opener to all but the completely stupidist of the stupid.

    BTW, I’ve invited my liberal congressman to my office but he has yet to respond (waiting 2 years now).

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