Monday, December 29, 2008

This Started Off As A "Highlights From Friday's Pill Counting Action" Post, But Honestly, This Is A Highlight That Deserves To Stand All On Its Own

It started as a routine reject. A quick phone call should straighten things out. 

Me: Yeah I'm calling about this reject message I'm getting, It says that only Prevacid Solutabs are covered for patients over 1. I think the rest of the message must have got cut off or something. 

Actually what I suspected was that Prevacid itself was non-formulary. Those of you in the profession know it is not unusual for an insurance reject message to bear little resemblance to the actual reason a claim is being rejected. A quick phone call and the nice lady would tell me which meds in the class were covered.  

Medco: No sir, that is correct, only the solutabs are covered for any patient over 1 year old.

Me: Ok, that can't be right. Do you know what a solutab is? It melts in your mouth, which makes them, you know, ideal for children.

Medco: Silence.

Me: Are you telling me if the patient is under 1 year old you would only cover the regular capsules?

Medco: The plan sponsor sets the parameters sir.

Me: That's not what I'm asking. If this customer was under 1 year old, I would have to give them the regular capsules. Is that how it works?

Medco: Yes.

Me: And since this person is over 1 year old, a fully grown adult actually, the only thing I can give them is the melt in your mouth version.

Medco: Silence

Me: I can only give them the solutab?

Medco: Yes.

Me: You realize.....that someone has obviously made a mistake here. A typo that should take like 2 seconds to correct. 

Medco: It's the plan sponsor that sets the parameters sir.

Me: You understand that these parameters involve asking a 1 year old baby to swallow a capsule while making an adult take the formula ideal for children

Medco: Yes.

Me: So you know this is stupid.

Medco: I understand your frustration, but I can't change the plan parameters sir.

Me: Ok, fine, but do you think that maybe you could contribute a little to the solution of this problem, like maybe telling your supervisor about this idiotic situation so they could perhaps open a line of communication to the people who set up the parameters?

Medco: Silence

Me: Can your kid swallow a capsule?

Medco: Is there anything else I can help you with?

Me: What exactly have you helped me with to this point?

Medco: Silence

Me: Is this call being recorded for training purposes? Because I think it really should be. Because this is....fu.....I stopped myself before the whole word came out because I knew that would be an automatic hang up and I wasn't done yet. I mocked the Medco lady. I ridiculed the Medco lady. I asked her if she was proud of the work she was doing. I was pretty Goddamn mean. I had to hand it to the Medco lady though. Cold. As. Ice. I was opening up on her with both barrels and there was no display of emotion, much less any budging. In the end, a 47 year old man got melt in your mouth Prevacid

And somewhere a baby just probably choked to death. It's a good thing we don't let the government run health care though, because if the government ran health care, then stupid bureaucratic shit would happen. 

Don't think the Canadians aren't laughing at us. 



Anonymous said...

You're a good pharmacist when you choose to give a shit...

Anonymous said...

We use the Prevacid capsules to make lansoprazole suspension, typically for kids, usually with feeding tubes. Is that why the capsule is covered? So that you can use it to make the suspension??

The SoluTabs are large enough, and take a while to dissolve. I can't see a small child able to hold it in their mouth long enough for it to dissolve.

Not sure why they wouldn't cover the capsules for adults.

Maybe that brings a small bit of sense to the apparent insanity. Not sure...

Carol said...

In Ontario, Canada at least, the solutab isn't covered AT ALL. For kids or otherwise. Not that we don't have our share of other stupid drug plan crap to deal with.

Anonymous said...

Funny, we ran accross the same plan last week. Our solution was to switch it to the solutab and get THAT to reget. Then we could call the plan to tell them how stupid it was. Imagine our surprise when the solutab actually went through. Our patient got the solutab too.

Dustin said...

I don't work for Medco, but I can tell you with a reasonable degree of certainty what the story was. Nexium is probably preferred, and since Nexium doesn't have a ODT version, they can still get the higher rebates from AZ for Nexium "Exclusive" while covering Prevacid (Solutabs only), with an age restriction.

Or, they don't have a preferred branded PPI (more common now that Prilosec OTC is not only cheap, but available as a generic), and cover Prevacid Solutabs because some whiny union member pointed out that there's no generic ODT version (actually, whiny union member works for Nexium scenario above as well). The >1 year age restriction is probably due to the fact that the ODT do take some time to dissolve, and so would not really be suited for infants.

BiteTheDust said...

It's not only the Canadians having a bit of a chuckle. The Aussies are as well.

Christine-Megan said...

I've taken Prevacid for awhile. my insurance gives me a hard time about it yearly. I got samples from my doctor's office to tithe me through til the PA was taken care of. They only had the solutab version. Those things tasted freakin' awesome. I want solutabs all the time!

But my version of Medco only covers capsules for adults ;)

Anonymous said...

But, a tablet would be easier to break if the dose was a significant fraction of a subdivided tablet.

It seems that the insurance 'makes' the decision that the capsules will have to be compounded in a multiple capsule formulation (most pharmacists realise one of the PPI drug forms for adding to feeding tubes plugged them.) Isn't diarrhea the consequence of too high a dose in kiddies? and, isn't diarrhea potentially of greater significance in those under age 1?

It's past time for those lawyers that want to make a 'killing' off malpractice for Viagra suits to get into the medical insurance wrongful settlement business. This makes just one more argument for single payor systems--at least a stupidity like this could be addressed by a class action suit.

Annapolitan said...

I am going to save your comments to the Medco rep so the next time I'm on with "customer care", I'll have crib notes for good comebacks to these cold-as-ice, I-can't-wait-to-end-my-shift, I-hate-my-job bots who populate the call center.

It may not do a thing, but it will make me feel better.

Mother Jones RN said...

You have given me another reason to love you. You care about people. And you're a smart ass.



Anonymous said...

"It's a good thing we don't let the government run health care though, because if the government ran health care, then stupid bureaucratic shit would happen.

Don't think the Canadians aren't laughing at us. "

Wait a minute.

The entire presidential campaign, all we heard out of you was how much better things were going to be when your guy got into office and we all got "Universal Healthcare".

What do you think that "Universal Healthcare" is going to be modeled on? The congressional system? Oh hell no! It's going to be modeled on that nasty mess of Tricare (hello, Medco) that you are making fun of.

Reap. Sow.

Nancy said...

As much as I hate calling Medco, Caremark is so much worse. At least when I call Medco, I usually get someone who speaks English, or I call so often I know the rep's voice.

Caremark on the other hand. Hoo boy. One day it took me 6 filters to get to the pharmacy help desk. 6 times I had to tell it I was calling from a pharmacy, all punching in my NPI and the Rx number in question.

You ever notice how Caremark refuses to give you a fill date on a refill too soon?

Drugmonkey, help me burn down the Caremark offices.

DKLA said...

Most likely its all based on Medco's managers/PBM (aka the replacement pharmacist) all-knowing and well founded decision (pfft...).

Of course well founded research is usually associated with more money in the pockets of lesser people.

If you can call them that these days.

Another soul-wrenching day of stupidity at the pillbox (for all of us).

Anonymous said...

I've had nearly that exact conversation with a MEDCO rep once. VERBATIM. Till the "FU..." I stopped with, "that is absolutely you realize what you're saying??" as I chuckled. Same plan, same situation.

The kicker is, that they make it CLEAR that its only covered for kids, while in most cases...a simple PA Req'd would be the reject message.

Its like they want to adervise their stupidity.

Anonymous said...

Why do I feel like I went to pharmacy school to deal with insurance, and they didn't teach us anything about this stuff

Romius T. said...

As always you frackin' crack me up...

AmyKate said...

Totally just had this same situation today. As much as I wanted to, I didn't call medco tell them how dumb they are. Because I learned a valuable lesson on your blog! Thanks from me and the 50 year old man who got his solutabs!

Beloved Parrot said...

Happy new year, drugmonkey. Yours is one of the blogs I'm addicted to, and I won't be going to the drugstore to find a cure.

Stavros69 said...

It is a wonderful system. Professional judgment is not allowed.
Bureaucracy rules!

TC said...

Hey, have you seen this?

Happy New Year.


Phrustrated Pharmacist said...

"Tank you for colling-a meedco, please hold while I access your information....." why does every Medco operator sound identical? Is it a robot? I've heard things...

Beth in TX said...

Haaaa!!! That was freakin' AWESOME!!!

Anonymous said...

I cant believe they are still doing this... but the reason behind it, as i was told, does have to do with the capsules only being covered for compounded infant scripts, and the rest, well, yeah totally stupid. However my favorite pbm call..... on pt. refill #2 the insurance reject for generic protonix, i have the doc change it to the displayed covered drug, ins rejects for "prior auth/dur" reasons.... why??? cause the patient had an similar med within the last 30 days! i actually lost it with the help desk person... seriously!

Madam Z said...

How do you drug monkeys keep your sanity? If I were in your shoes (do monkeys wear shoes??), I'd be swallowing some non-prescribed "calming agents" to get me through the dreaded insurance swamp.

asdf said...

I dealt with the exact same situation today. The pharmacist on duty was aghast, but I knew exactly what was going on because of this blog. Saved us a phone call.

Anonymous said...

little drug monkey did you tie a big one new year's eve? need a new blog fix here....happy new year

DrugMonkey, Master of Pharmacy said...

Anonymous #5,

"What do you think that "Universal Healthcare" is going to be modeled on? The congressional system? Oh hell no! It's going to be modeled on that nasty mess of Tricare (hello, Medco) that you are making fun of."

Really? Because you know, President elect Obama's (God i love typing those words. I'm gonna do it again right now. President elect Obama) incoming Health and Human Services Secretary, Tom Daschle, just wrote a book in which his outline for solving the nation's health care crisis involves......a major expansion of the Congressional health system. Looking through the index, I don't see Tricare or Medco mentioned a single time.

In other words, you're full of shit. Don't come into my house and comment when you don't know what you're talking about. Because I won't hesitate to get out my fact claws and rip you to shreds when you do.

You're lucky i'm in a good mood.

Utah Savage said...

I love you when you tell the truth so ferociously. I waded through all those comments for that one moment when you call "Bullshit1"

Anonymous said...

I have a habit of saving my insurance rejects for the end of the shift on the weekend. Then after the pharmacy is closed I make the calls. Typically I will get a female representative with a sexy southern accent. I then hit on her relentlessly for the entire time we fix the insurance reject. I think it makes both of our jobs a little more bearable.

Anonymous said...

the plan sponsor dicides whether Prevacid or Prevacid solutabs is covered?!? What a bunch of bullshit. The plan sponsor doesn't know shit form shinola about different versions of drugs.
MEDCO makes the choice, yes, as your readers have pointed out, based on kick backs. I had a Medco flunky try to tell me that the plan sponsor dictated that patients could not exceed 6 days early on a refill over a 6 months period. In fact, she explained all their plan sponsors had requested that feature. I expressed my surprise that 3000 plan sponsors had come up with the same idea in the same month. She was not happy with my observation and the conversation was discontinued.

Anonymous said...

I'm a tech and I'm AMAZED at some of the reasoning from the insurance companies. I had a rejection for bad birthdate. No big deal, double checked with the customer to make sure we had it right. We did. I called the insurance thinking this would take 5 seconds to find out what birthday on file. That was not to be. I spent the next 30 minutes going round and round with the insurance agent because they couldn't give me any info on the patient since I didn't have their birthday.............I was getting a flippin bad birth date rejection and had every other piece of info on the patient to confirm who they were. The customer ended up having to pay cash!

Anonymous said...

Having worked for Medco, I can assure you that logic is no prerequisite for policy. And in defense of the poor representatives taking calls, they quickly that trying to fix anything by approaching management is a completely futile effort that only stands to harm the person trying to "fix" the system.

Anonymous said...

I know a lot of plans follow the FDA guidelines for medications. Prevacid Solutabs are not FDA approved for children under 1 year of age. That is why it is not covered for children under 1 year of age.

Anonymous said...

As of February 2009 the insurance company (the same one you're dealing with) wont cover this drug at all and my son really needs it -not the solutabs or the pills! I know your dealings were bad, but now they won't cover them at all. We have to pay full price (which is huge).

Anonymous said...

Get the "crap" out of healthcare. Flush a PBM.