Category Archives: Insurance Companies

The big socialized medicine post

Here I will give my thoughts and viewpoint on the current push to give people socialized medicine in the US.  Feel free to chime in on what you think.

As all of you are quite aware, there is a push in this country to give every man-woman-child government sponsored health-care.  Here I will tell you why this is a horrible idea and is doomed to fail.

Here in the wonderful USA, we already have 2 forms of socialized medicine:

  • MediCare – Given to citizens over the age of 65, or to those under 65 who qualify (renal disease, disability, etc)
  • MediAid – Welfare

Both of these are wholly sponsored and paid-for by Uncle Sam.  Sure Medicare Part D plans have a small premium, but usually those are taken out of your MediCare check (and are no where near the cost of private insurance).

What this socialized medicine bullshit wants to do, is to give “universal health-care” to people who do not fit within those two categories.  Now mind you, that anyone can go to any county hospital (paid for by the taxpaying citizens of that county) and receive medical care without having the ability to pay.  Most private hospital ER rooms will also give you stabilizing treatment without you showing proof of ability to pay.  That seems pretty damn awesome if you ask me, however people want more.

The big idea that some Americans throw around is that access to health-care is a right.  Let me clarify this for everyone who thinks that way:


Access to a Doctor is as much as right as having access to a Plumber, a Roofer, an Electrician or anyone else in a specialized trade.  Until the government FORCES AND PAYS people to go to medical school, it is not a right. You see us Doctors, Nurses, Pharmacists? We chose to go into this profession, we weren’t forced into doing it.  Do you see an amendment in the Constitution showing the right to see a medical professional? No. Do you know how to re-shingle your roof, install a shower, fix a rotting foundation, lay brick, or do a bunch of other jobs that you have NO PROBLEM hiring someone to do; but the moment you can’t get in to see the doctor RIGHT NOW (because his/her practice revolves around YOU) the “I HAVE A RIGHT” card gets thrown down as you throw a 2 year old tantrum?   Quit fucking whining about your “right” to see a doctor and be thankful there’s more than 1 doctor in 300 square miles like in some 3rd world countries.  Be thankful we even have people who choose to be doctors, pharmacists and nurses after dealing with shit-ass people like you.

Now that we cleared up that “confusion” that some entitlement douches like to throw around, we can move on why socialized medicine will not work here:


Irresponsible humans have a nasty of habit of seeing “free” and totally abusing the shit out of it thinking it is indeed free when its not.  Its free to them, but costly to someone else.  Let me give you a situation:  You have a sore throat.  You should probably go and see the doctor but you might want to wait another day.  Judging that you can see the doctor “RIGHT NOW”, are you more willing to go if its going to cost you a $100 copay, or $0 copay?  Now imagine EVERYONE doing this to the same doctors office.  Now get really mad when your appointment is 3 years away, and the doctor sees you for 30 seconds.  Now bitch about something that you get for free off of the backs of the working class.

As evidenced by the MediCare system (why do old people need so many fucking lab tests.. OH ITS FREE!) and the welfare system (I need my Nexium, Diovan, but I only really take my VICODIN), if something is perceived as free it will be used, abused, and taken for granted.   Just look at e-mail and the internet for example.  People believe that email is free, so as a result I get thousands of spam messages a day to my inbox.  People believe that its free for me to run this site, so they have scripts setup to check it every 30 seconds for new content (if you’re slow, you wouldn’t realize that I try to post something every SUNDAY).  Humans abuse what is free.

I’m sure the Canadian and the UK readers will share how most of them have PRIVATE insurance because the socialized stuff has a 4 year waiting list for appointments for the socialized docs.  Hate to say it, but copays filter out the “I must see doctor!” from the “Eh, im bored, lets go get drugs”.  If you don’t believe me, go sit in the ER and see what piddly shit comes in to waste our dollars.


Yeah, we’re broke.  We bailed out every corporation that should of failed (will Obama bail out my pharmacy and the other independents when the insurance companies force us under? No) and have a few trillion dollars of unaccounted free money (our money) floating around.  Now how exactly are we going to pay for this?  I’m paying into a MediCare system that will be long dried up before I ever get to get a lab or appointment covered by it.  Medicare part D has to have the ‘coverage gap’ to keep it from going broke (faster), and now we want to give subsidized health care to everyone?  Reading above how people abuse what is free doesn’t really make much sense that this is going to financially fly.  The government couldn’t throw a 5 year old’s birthday party without tons of red tape and spending 100x what is would normally cost and there is talk about making them have a hand in our health-care?  I think this whole ‘universal healthcare’ is just a government ploy to give new jobs to the idiots who work on the federal dime so they can keep their meaningless pointless jobs.

So I don’t really know what the future holds if we have socialized medicine in this country.  It might look good on paper, but I think its going to flop.  At least I’ll get my opinions in before the government forbids me from giving them (or maybe the’ll just take over this website like they are taking over everything else in this country). 😉

UPDATE: Look, less than 24 hours and already I’m trying to explain what I wrote.  So this post was to clarify on how I think that healthcare is not a right (which it’s not, disagree if you will)  and two huge issues that any government subsudized plan is going to have (which could apply to ANYTHING that ANYONE pays to service that someone else uses)  It wasn’t “YAR YAR NO SOCIALIZED MEDICINE” like the words some of you are putting in my mouth.  Since /any/ plan that is made by our broke government is going to be 1000% funded on the backs of taxpaying citizens (since obviously doctors aren’t going to take a huge pay cut, pharmacies aren’t going to take a huge pay cut, where is the cash going to magically come from?) these are the concerns I have (and rightfully so).  Like one reader said, we can’t take the usual government approach and throw this together, dust off our hands, and pat each other on the back.  You would think that most of you who dealt with the Medicare Part-D bullshit would understand that.  This is huge, and its with our money, so we should demand that it be perfect, well thought out, or we’re just throwing money away.  And to the federal workers to got offended by my joke about the ‘government conspiracy’, get back to work, quit wasting time reading my website, and dont be so easily offended by the unfaulting sweeping brush that I make jokes under.

Workmans Comp – The working mans welfare

Every pharmacist has had to deal with Workman’s Compensation prescriptions at some point in their careers.  They usually involve paper billing (although now Express Scripts, RESTAT and others have made them electronic) and a lot of begging/paperwork to get paid.

Pharmacists see this all the time, but its a little known fact that work-comp has become the “richs mans Medicaid”.  It has spiraled so out of control, and gotten so outrageous that now I view it as just another form of welfare.

How its supposed to work:

You get injured on the job via some fault other than you being an idiot.  Equipment fails, your employer had something go wrong, some freak accident happens.  Work comp then pays  for your doctors visit and medications.  If you cannot perform that job any longer, you find another job doing something that doesn’t require a bad back or missing fingers, etc.  You continue to work, your (former) employer’s work comp insurance premiums go up, and life goes on.

How pharmacists see it work (ie: how it really works):

You were at work and get injured because you’re a fucking lazy idiot (with your head firmly planted up ass) and go to the ER for a smashed pinky finger.  They give you an Rx for 40 vicodin and some ibuprofen and keep you off work for 3 weeks.  You (and your work comp lawyer) then sue your former employer giving you full paid time off.  You relax and go on vacation and do other fun stuff with your wife and kids while receiving a fat work-comp check (and free medications).  You OBVIOUSLY cannot work any longer because of the MENTAL ANGUISH of having a mangled up pinky finger.  It is SO HORRIBLE that you then obtain full disability and never have to work again.

Yeah, its really like that.  I’ve seen people get a few medications (like ibuprofen and like 20 vicodin every other month) and continue to work.  All the work comp pays for is just a few doctors visits a year, and 2 measly prescriptions that are filled once every 45 to 50 days (and they are 20 day supplies at that).  I’ve also seen people who have basically nothing happen to them, go off work fully, get medicare prematurely because they are “disabled”, then have me try to get vacation overrides for their cruise to the Bahamas.

It all comes down to how well you can play up your “injury” and how good of a scumbag work-comp lawyer you can hire.  Work comp is raped to the point where the premiums are outrageous for employers, and more and more people (read: police officers; that’s right, I’m calling your ass out) are comping out just before retirement so they can collect their fat retirement check along with their work-comp check.  Their reason? MENTAL ANGUISH.  Yeah, try to work as a pharmacist for 30 years and see what kind of mental anguish you get from dealing with the same ghetto public without a bulletproof vest, a gun, backup, and a radio to call for help.  Another reason why hanging your head in the public trough of state-worker is the way to go.

If dealing with the scamming-free loading work-comp abusers wasn’t enough (as they brag to you about their next vacation, knowing that you’re working hard and they are just freeloading from a system that cant say ‘no’); processing a work-comp prescription is a nightmare all in itself.  Some companies make you call a 800 number EVERY TIME YOU FILL AN RX so the processor can get approval from the comp adjuster (the person who decides if your drugs are needed for your comp condition, a position that is filled by an idiot with zero medical knowledge what so ever).  Now I admit that it was better then the old days where the pharmacist had to track the adjuster down, but you also got paid a whole lot more for those paper billings vs electronic billings.

Personally, if I was king of the work-comp world, unless your injury left you permanently handicapped or mentally disabled (ie: a vegetable), all of you leeching fucks would be at a desk job, a greeter at Walmart, or any of the 100 million jobs out there that does NOT INVOLVE THE PART OF YOU THAT WAS INJURED.  Just because you are a lazy fuck who got hurt because you had your head up your ass, it doesn’t mean that us HARD WORKING PEOPLE (including those who are on comp yet find another job) HAVE TO PAY FOR YOUR FREELOADING LAZY ASS.

Maybe your injury wasn’t your fault, but sure as shit it wasn’t mine, so why should my premiums go up because of your fuckup?  Sounds more and more like the welfare system to me.

MediCal pissing in our cornflakes.

I’m sure this post is full of grammar and spelling mistakes. To all the people who like to point them out, go fuck yourself.  I’m a pharmacist, not some soft-science English major douchebag.  If you are the type who likes perfect English and grammar, then go to a squishy website that reeks of deep literary self-masturbation.  If you are the type that wants to see the ‘real story’ of pharmacy, read bad words, have dirty sex with multiple Thai hookers while drinking Jack Daniels from their unwashed hoo-hahs, welcome to the party and ignore the shitty grammar.  Remember, PHARMACIST not PROFESSIONAL WRITER.

As of the first of February, MediCal (that’s California Medicaid for those out of state) decided to take a big steamy dump on the faces of pharmacies/pharmacists.  No, these are not the 10% cuts that I wrote about before, but something equally as stupid.

Before 2/1/09, if you had the patient’s Social Security Number, you could query either by POS device (a little credit-card looking machine that dialed into Medical) or their phone Automatic Eligibility Verification System (AEVS).  The little tape/magical voice on the phone would tell you the patients MediCal ID number (because we cannot use the Social for billing anymore).  Took about 1 min to do, and saved a bunch of time/trouble when the idiot forgot his/her card (or lost it (surprise)).

Now everyone who deals with Medicaid patients realizes that these people can’t even manage a $5, let alone be responsible enough to carry their MediCal card with them.  I mean shit, their Vicodin and Soma get lost every other week!  The POS/AEVS system made it easy.  They tell you their SS#, you get their MediCal number, no card required!

Well, they shitcanned that service.  That’s right, if you do not have the patients MediCal number you cannot get it via their Social Security number.  Let me tell you why I’m writing about this.

See that patient coming in the pharmacy at 6:30pm on a Friday night with that Rx for Levaquin?  He can’t get that because he doesn’t have his card on him (and he’s not in your system).  Doesn’t matter if you call MediCal and talk to a person, they refuse to give out MediCal ID number over the phone INCLUDING TO THE PATIENT THEMSELF!!!  This means the patient must GO TO THE SOCIAL SERVICES OFFICE and get a paper printout with their ID number on it.  Since MediCal is a government operation, lets put money on their hours of operation including weekends and all major (ie: every damn made up) holiday off.  Their social workers (for having ‘worker’ in their title, I have yet to see one actually ‘work’ or is worth the air they breathe)  can also provide them their number.  Yes, entrust someone with a few semesters of useless squishy classes with access to their ID numbers, not their pharmacist.

Now here we are at the rubber meeting the road.  You have a teenager or child with expensive antibiotics/medication that MediCal usually covers but they have no card (and obviously are not in your computer) Are you going to trust a MediCal patient with $200 of antibiotics to come in Monday morning with his card so you can bill for them?  Fuck no!  They have no incentive to help you out even though you helped them out.  Face it, its a fact.  Laziness beats ‘whats right’.  Fuck this ‘give some now and hold the rest’, you wont see them again!  Most of these people need to prepay for their Soma that is due TOMORROW because they don’t have the self control to keep that money in their pocket UNTIL TOMORROW!!  For the majority of them, if they had any ounce of responsibility in them, would they be in the situation they are in now?  I know I’m infamous for making blatant blanket statements on here, but how many hundreds of dollars must be lost on “whats right” before you put your foot down?  Why don’t you just dispense #100 vicodin/soma every other day because the patient is “in pain”.

You want to complain about this? Good luck, the MediCal office hires the most stupid, ignorant, minimum wage retarded dropouts on the planet.  You know all the “stupid people” in the Health Care profession I rant about?  Yeah, all of them are GENIUSES compared to MediCal phone operators.  It took 4 (FOUR!!) people to try to get the idea across how much of a BAD IDEA eliminating this service is for not only the patients but the pharmacies that service them.  They just didn’t get it.  One of which told me “I don’t see why you pharmacists make a big deal about this, just ask them for their card”.  *sigh* I almost died.  In fact, as I type this my soul died.

Requests for a complain phone number/email gave me a “There is none”.    I guess MediCal patients have no rights to voice a complaint about the care they are getting (but to be honest, why would a MediCal patient complain?  Their formulary is beat only by the magical CASH insurance).

So I told them “I am going to turn away every new patient who does not have their card because you have forced me to make the choice to either take a loss on their Rx’s, or to not give them medicine.”  They just said “uh huh” a lot.  I must of used too many words too fast for their small brains to comprehend.

Now the ironic part of it is that I always bitch about how we need to make the Welfare folk more responsible, and them not having their cards (and thereby not having their medication and dying) would in fact pound some responsibility into their brains.  However what kills my soul (more) are the kids who really need antibiotics and due to mommy and daddy being ‘winners of life’ (by losing their ID card) get doubly fucked over by this change.  You are forcing their medications to ride on a card given to someone who can’t be entrusted to always have the card, however I guess that’s the same argument with a child isn’t it?

I’m hoping this is just a huge oversight that will be taken care of.  However if you, your staff, or your patients have been effected by this, please comment and maybe MediCal will get the idea (hah! right).

Medicare Part D – D-Day all over again.

No no, I’m not going to give our dear friend Ken a good beat-down like some of you have been hoping.  I’ll get my revenge when he asks for his Vicodin and Soma a week early and his doctor and I (in some “fuck fuck paternalistic plot fuck fuck” tell him to go “paternally fuck” himself).  Besides, you all have shown him the errors of his life way better than I could.  Seriously, 50 comments and counting wasting this douche bag surprised the hell out of me.

Before I start bitching about old people and Medicare part D, I would like to bring to light the best comment I think I have ever received.

All you people who think TAP is so funny and so smart. You know who you
are. The ones who come here daily and encourage him and his behavior.
Will you still be proud of yourself when this human time bomb goes to
work one day and shoots up a group of innocent people? There is no one
more psycho and disgruntled than TAP. You people couldn’t care less
about him. If you did you would try to help him with his displaced
anger, instead of being the enablers that you are. I hope when you read
about him in the newspaper one day, you take your share of the guilt.

Wait, are you saying that there is nobody on this earth more psycho and disgruntled than me?  Oh how my heart flutters with bile and hatred!  Take that Angriest Pharmacist and DrugMonkey!  Have you gotten a comment saying that you’re a time bomb? Have you gotten anything that predicts you murdering a bunch of innocent people?  No!  Me – 1 and You – 0!  But realistically, “try to help him with his displaced anger”? Give me a break.  This isn’t a self-help group therapy site!  Lets all sit around the ScriptPro and sing songs of peace.  Obviously Marcia W, poster of the comment above, needs a big helping of the clue-bat to realize what kind of site this is.  Of course she agrees with Ken, so shes probably with Ken asking if he can get his narcs early if she pays for them with a two-party check.

Anyway, since this isn’t the Ken and Marcia show, and all of you “enablers” out there (50+ comments and counting!) are about to get fucked over on the first of this year, lets get back to the task at hand.

I have an idea.  Lets take a insurance plan and make it as complicated as possible.  Lets add shit like deductibles, a coverage gap (aka: doughnut hole), catastrophic coverage, multi-tiered copay systems, the works.  Now lets force the one class of people who have the least amount of understanding: The Old.  Now lets pawn the explanation of everything to our local pharmacist who we will pay $2.00 above cost for this service.  Lets send out ID cards with the wrong information on them as well send deceptive ads and salesmen around to complicate and confuse things even more.

That boys and girls, is Medicare Part D, and its the utter-clusterfuck of pharmacy.  They have made the absolute complex insurance plan possible and forced the old and stupid to use it.  Lets face it, the 65+ crowd aren’t the sharpest crayons in the box and are the most willing to bitch and moan.

On the first of the new year, retail pharmacy as a collective will either stick the proverbial shotgun in their mouths and pull the trigger, or will drink themselves into oblivion.  On the first is when all of the deductibles reset (and yes, you WILL have to explain what a deductible is to the same patient for the nth time in a row), plans merge, shuffle around, Argus and Wellpoint go down, etc.  Its going to be a mess.

However seniors, being old and confusable, forget about a few years ago when there was no Medicare Part D and they had to PAY OUT OF POCKET FOR EVERYTHING minus that measly discount the Medicare card gave them.  How quickly they bitch about $3.10 COMPLETELY FORGETTING they were paying $65 just a few years ago.  “I’m old and I deserve something.”  Yeah, well I’m not old, you’re using up the Medicare money that I put in but will never see, and I hope your little electric scooter shorts out in the parking lot so I can laugh at you.  You would think they would learn the routine now that Medicare part D has been out for 4? 5? years.  Yeah, you would think.

I’ve said it before and I’ll say it again, that Medicare Part D is a mean and cruel joke on the old and stupid and revenge on pharmacists.

I’m dreading the first

Fixed Income Medicare Blues

I know I haven’t been posting lately compared to my DrugMonkey and Angriest counterparts.  Don’t feel like getting into politics here and I dont like to rehash stuff (too much).  Had to reprime the angry-reserves. 🙂

People always sing to me the ‘I’m on a fixed income” blues when they are paying their Medicare Part-D $3.10 copays for their $200 Nexium Rx.  Oh, how soon these idiots forget what life was like before Medicare Part-D took effect.  Did they somehow forget paying full price out of pocket for their medications?  Why is now $3.10 so much of a financial drain on their “fixed income” when just 4 years ago they were paying 10x that amount with a smile on their face.  I really do get a huge hard-on when I bring up how much they were paying before Part-D and how they are only paying $3.10 (which makes them feel like huge ungrateful douches).

Medicare Part D has spoiled seniors, plain and simple.  They are so hung up on their “fixed income” that they have completely lost sight that the people who are footing the bill for their expensive medications are the same people who will never ever see a dime of the money that they contributed to the system.  They also fail to see how Medicare is pretty much socialized medicine for people over 65, and we can see how well THATS going.  Medicare recipients complaining how we should have socialized medicine in this country just makes my irony meter fly off of the chart.

What do you expect from old people other than cow eyes, the same question asked every week, and bitching about $3.10 copays.

When chains rule the world…

Although they sure as hell don’t realize it, PBM’s (like  really do need small independents to continue their existence.

Imagine if you will, when all of the PBM’s have driven all of the little guys out of business.  No more mom and pop stores as far as the eye can see.  Sure, this might make the PBM’s happy because their executives got a 4.5 hochillion dollar bonus this year off of the backs of the little guys they put under, but now they have to deal with the two big angry gorillas of the pharmacy world:  CVS and Walgreens.

Now, when MedImpact/Argus/etc sends their contracts to these retail giants with their AWP-25%+0.07 rates, do you think that the two big boys on the block are going to sign that?  Hell no.

You see, now they sorta have to, because independents are still around to take care of the patients if the big “evil” chains refuse to sign that contract.  Its illegal under anti-trust acts for true independents to collectively refuse to sign a contract.  So you’ll find at least one pharmacy in town who’s enough about “Patient Care” to sign that horribly low reimbursement rate.  However when we’re all gone? It’ll just be the big boys, and they have a LOT of stores and don’t like to use much lube when it comes to the bottom line.

MedImpact will waltz up to CVS and offer something horribly stupid (because thats how PBM’s roll).  CVS will look at the contract, send it around to each store for the pharmacist to wipe his/her ass on it, then return it to MedImpact.  If they terminate CVS’s contract, then MedImpact’s patients just lost about 1/3 of the stores they can get their Rx’s filled.  Walgreens will do the same thing, and eventually you’ll have a PBM that has no pharmacy to call home.  See, the PBM’s will have eliminated all of the competition of the chains vs independents.  They don’t realize it yet, but its slowly happening.

So whats a PBM to do?  Easy, stop fucking over pharmacies.  Take a REASONABLE fee for processing the prescription (ie: don’t make more per Rx then the person who is filling the prescription like you are doing now), PRINT THE RIGHT INFORMATION ON THE FUCKING ID CARDS (so we don’t have to call), and stop being fucking slimy crooked piece of shit banes of the pharmacy world.

Which brings me to my second issue:  At what point do we throw down the gauntlet and put ‘patient care’ aside for our own livelihood and well being?  At what point to we refuse to sign the new contract that these pieces of shits send our way and collectively stand as a profession against the abusive-husband that we call PBM’s?  When do we grow the balls to tell Mrs Smith “I’m sorry, but we no longer take your insurance because doing so will cause us to go under.  Go and complain to your insurance company about their processor”.

You know how I rant on here about how annoying and stupid patients can be?  Now imagine them not yelling at me, but having them collectively yell at the PEOPLE THEY PAY to manage their pharmacy benefits.  Of course trying to get pharmacists to do anything collectively is like herding cats; and we probably need a committee, a fancy name that has a cool acronym like DILDO, yearly meetings with pharmacy school students, a publication, lots of pictures of people who have NEVER WORKED A FUCKING HONEST DAY IN THEIR LIVES with fancy letters after their names, award ceremonies for “Something” of the year (which means absolutely nothing), scholarships, more publications, requests for membership dues, etc.

Thats right, I’m ragging on CPhA, APhA, ASCP, and the other alphabet soup organizations who want me to join their organization in exchange for magazines full of pictures of students who don’t have a fucking clue and old-guys trying to re-live their glory college days.  WHY AREN’T ANY OF THESE “organizations” DOING SOMETHING ABOUT THE PBMS!!!  Oh, because they have no idea about PBM’s because THEY DON’T WORK RETAIL.  Before you can “Advance the Profession of Pharmacy(tm)(r)(wtf)” why don’t you try to fix the insurance clusterfuck that we have going on now.  I know that its hard work shaking hands and getting your picture taken at the latest convention at the Marriott, but seriously, DO SOMETHING or we’re going to have to take your “patient care” that you so dearly hold true and preach to everyone about (btw, whens the last time you even SAW a patient? How about actually worked in a pharmacy?) and throw it aside so we can pay make payroll.  Roll up your sleeves, put your fancy labcoat (with your name embroidered on it and has never seen a pink amoxicillin stain) aside, and GO AFTER THE PBMS!

The organizations should be going to the PBM’s and say “The cost of doing business is $x.  At your reimbursement price, pharmacies CANNOT survive.  We are going to recommend to ALL OF OUR MEMBERS to not sign up with your plan.”  Anti-Trust? Sorta, but this is to all the members, most of which who are chain pharmacists and non-owners.  Bah, its a pipe dream.  Maybe they are doing this, but seriously to the guy in the trenches whom it effects, I see zero.

Realistically, I’m betting on the chains to do the dirty work based solely on their monopoly on the industry vs the people that I pay dues to represent how I see the profession.

When bad PBM’s get even worse

Over the last 200+ entries, I have fought for truth, justice and AWP -5% + $6.50.  I’ve laid down the smack against doctors, other pharmacists, drug-reps, insurance companies, Liberty Medical (fuck you) and even myself.  Now someone else is on the angry chopping block.  This rant is a magical mix of useful information and gutter-talk.  My mother is probably so ashamed right now, however like most of our readers she forgets this is the ANGRY pharmacy and not

Like a pimp who never loved you, these assholes of our profession both give us money, and screw our asses when we’re not looking.  Can’t live with them, cant work with them, but like a case of herpes wont ever be completely gone.

Yes, I’m talking about PBMs.  Pharmacy Benefit Managers.  The people who process your prescriptions and write out your checks every month.  WellPoint, Argus, Medco are all examples of PBM’s.  See on your insurance card at the Bin and PCN (Processor Control Number)? Thats so we can transmit to the correct PBM to get paid for your Vicodin and Soma.

You look confused (surprise surprise), let me use an example.

For those not in the profession (and 99% of the doctors out there), most insurance companies don’t administer their own pharmacy benefits.  Say for example we have a small Medicaid plan called “HealthPlan of AngryLand” (HPAL) that has hired a PBM called PillConcussion (PC) to process the pharmacy benefits.  When your local pharmacy processes that Rx for Soma, our computer systems contact PillConcussions servers (whom have a list of medications that HPAL has deemed “covered”) and right then we get a response if its covered and how much we are making.

PillConsussion pays the pharmacy for the Rx (say, $15).  HPAL pays PillConsussion what they paid the pharmacy ($15) + a handling fee (remember this!, more later).  So the flow of money goes:

State -> HPAL -> PC -> Pharmacy -> TAP -> Webhosting Bill/Booze/Hookers/Blow/Therapy.

Now, the big boys (BlueCross, Medco) process their own Rx’s, so the actual insurance company and the PBM are one in the same.  However smaller insurance companies cannot afford the infrastructure to process their own prescriptions so they hire a PBM (like PillConcussion) to mange their Pharmacy Benefits (hence the term Pharmacy Benefit Manager).  Now, this all may look fair and good, but what if PC goes crooked?

Example 1:
Brand new generic comes out.  Say its Paxil CR.  Now imagine that you have your head up your ass, and you processed the script for the trade name (because the patient has been on it for years) without switching it over to generic (which until this point you had no idea it was out).  Unless you look carefully at your reimbursement screen, the PBM will silently accept the transmission for BRAND NAME and reimburse you the price of the GENERIC (remember, you are transmitting the NDC of the TRADE name product).  No warning from their end, no “BRAND NAME NOT COVERED”, just a normal billing acceptance for about 95% under-cost.  That means that the pharmacy is getting the generic reimbursement ($4.00) when the PBM knows they are billing for the brand name ($200).  Your store just lost a shit-pot full of money because you blew past the reimbursement screen (although most pharmacy systems will blare warning lights at that point).  What makes this whole ass-raping even sweeter is that usually this shit happens when a new generic is released that the PBM’s know about long before you do.  Its pretty sad when the pharmacies find out that a new generic is available by the PBM’s gently patting your behind while softly telling you to lube up and bend over.

Example 2:
Say we take something random and stupid like Prilosec OTC and its generic Omeprazole OTC.  Now what if PillConsussion /only/ covers Prilosec OTC (the brand name), but reimburses the pharmacy the cost based upon Omeprazole OTC (the generic) and at the same time charges HealthPlan of AngryLand the cost of Prilosec OTC?   PC is billing HPAL the cost of the BRAND name, but reimbursing the pharmacy a cost based on the GENERIC.  Is this fraud? Would this be like the pharmacy billing trade name Cipro to the insurance company but dispensing the generic?  Its not as uncommon as you think, however most pharmacies are too busy/stupid to look at how little they are making and not speaking up.

Now in this example say that HPAL and the pharmacy talk and compare notes.  Like a guy who realized the girl he just nailed was 16, PillConcussion starts to do damage control.  They state that generic Omprazole OTC is not covered because the BRAND name is Omeprazole Magnesium and the GENERIC is just Omeprazole and they are not equivalent…

….Must ….Resist ….PBM ….Backward …Logic

Still doesn’t explain why they will not cover the generic but reimburse based upon the cost of the generic.. They then say that it was a computer error, and to BACK OUT AND RESUBMIT ALL CLAIMS FOR THE PAST X MONTHS.  Now here is what really confuses me.

If PillConcussion audited you, and realized that you were overcharging for a certain drug, would they have you BACK OUT and RESUBMIT all of the incorrectly billed claims? FUCK NO! They would just take ($difference x claims) out of your next check.  Now why can’t they do that with the errors that THEY made?  They know how much the price was off in the computer, and they know how many claims were processed, so why cant they just issue refunds to the Pharmacy (whom they were under-reimbursing) and to HPAL (whom they were overbilling).  Its bullshit that they make US do the work for something THEY fucked up on.  “I’m sorry that we fucked you, now get fucked even more with the $0.20/transmission charge you will get to BACK OUT and RESUBMIT to get an additional $0.50/rx”

Yeah, hear that sloshing noise, that’s coming from your backside.  Someone is getting the good end of this deal, and its not HPAL nor the pharmacy.  The processor is making MORE per Rx than the pharmacy, and all they have to do is just have a handful of servers setup to do processing.  The patients don’t even call them (nor know they exist).

This rant was started by an email I received about a PBM that is plaguing a good friend of mine.  I sent off a few emails to people in the area (I know a metric (not imperial) buttload of pharmacists everywhere, ah, fame) asking them about said PBM, and I received the same gripes/complaints from all of them.  This one however took the proverbial cake.

    I knew I was getting
fucked, but didn’t realize whose dick was in my ass.  All this time, I have
been blaming the insurance companies (who are not innocent by any means),
but it is the PBM that is really putting it to pharmacy and the health
plans.  These cock-smokers lower our MACs on a whim.  Hell, they
are lowering them before the fucking generic hits the
market.  Mean while you would think they would be lowering the
cost on those same meds to the health plan–no fucking way, the PBM pays us less
and doesn’t pass on the savings to the health plans.  Try to get
these same assholes to raise the MAC when
price goes up — good luck Charlie.  If you forget to dot an
i, they point that out without addressing the problem.  The cock-suckers
must be deaf and mute, because they can only communicate by email. 
If you work up the ladder at the PBM you begin to find
older pharmacist who at one time had their own pharmacies.  I have
to think they either couldn’t cut it without daddy’s money or tried to
fuck the public too much.  It is an IMPACT
we cannot afford to ignore.  You owners out there have a
choice–either stand up or lay down like a beaten dog.  Take the time to go
after these assholes now.

Now I’ve been sitting on this post for a long time, because this PBM decides to shoot themselves in the foot time after time (and I don’t want to make 100 posts about how shitty they are).  I just received an email from this same pharmacist saying that this PBM he is talking about (the one that has made an IMPACT on him) is doing an on-site audit at the end of August.  However they just audited him in March and found no significant errors (only stupid shit like a 1oz tube of cream being billed at 29gm instead of 28.95gm).  Now, I realize that sometimes we can be a bit slow, but since when do PBM’s audit you TWICE in 4 months unless you call them out on something huge and they want to get even.  What does a call to the auditor result in? “Oh, we’re sorry, this is a COMPUTER ERROR we will cancel the audit right now.”  Right, a “mistake” and a “computer error”.

So I’m just going to post this now, because I doubt that this PBM can shoot themselves in the foot any worse than they already do.