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No, [PBM], I will not assist you in causing me to lose money.

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  • No, [PBM], I will not assist you in causing me to lose money.

    I have honestly no idea where else to put this, so since it happened in a drugstore, it's going here.

    I get a call this afternoon from a certain PBM (Pharmacy Benefit Manager). Won't name it outright since I still have hopes of going back to work for the pharmacy chain that owns it, one of these days, but let's just say that it's affiliated with the Chain of Very-large Stores. Note that I work in an independent pharmacy within a grocery in a very insular village, and we get very few customers from outside the village.

    Them: "I have a client here who's looking to fill a prescription for Timoptic-XE, and they're having trouble finding a store who has it. Do you have that in stock?"

    (Timoptic-XE is a beta-blocker for opthalmic use, for treating glaucoma. The generic came out a few years ago. The "XE" means it's a gel-forming solution, typically used at bedtime for longer action, but not usually in the daytime because it can blur the vision.)

    Me: "Brand-name Timoptic XE, or generic timolol GFS?"

    Them: "They're looking for the brand name."

    Me: (checks wholesaler's website) "I don't have it in stock, but my wholesaler does, and I can get it in tomorrow. How much do they need?" (note: it comes in 2.5ml and 5ml sizes)

    Them: "They need three 5ml tubes for a 90 day supply. We've authorized it for a vacation supply. It won't go through for that, you'll have to call us for the override when you fill it."

    (Well thanks for the heads up, but this is beginning to look like it's going to be a pain in the neck.)

    Me: "I suppose I can do that."

    (Suddenly, I get an inkling. Something occurs to me to check...)

    Me: "Wait, though. How much is the reimbursement for that?"

    Them: "I can run it through on their plan and see what comes back. Hold a moment please... OK, the reimbursement is $315.27." (OK, I don't remember the exact amount, but it was in that range.)

    Me: (checks price) "Well, since my cost for three tubes of the brand-name product is $455.82, I don't think I'll be ordering that. Sorry."

    Them: "OK, thanks for your assistance. Have a nice day."

    Yup, you read correctly. They actually expected me to fill this transfer prescription, for a patient who isn't even a customer of ours, and who moreover will require me to call them and wait on hold for them to put the vacation override through for him, and take a loss of over a hundred dollars on the transaction.

    Not. Happening.

  • #2
    Yah, I can't think of what company that would. You don't stay in business by making loses on products like that.

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    • #3
      File it under "they had to try".
      Fool me once, shame on you. Fool me twice, you speak with the Fraud department. -- CrazedClerkthe2nd
      OW! Rolled my eyes too hard, saw my brain. -- Seanette
      she seems to top me in crazy, and I'm enough crazy for my family. -- Cooper
      Yes, I am evil. What's your point? -- Jester

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      • #4
        Thats a 100% reimbursement on their end? O_o

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        • #5
          Help me out here, since I'm definitely missing something: When the insurance reimbursement is only a portion of the cost of the meds, don't the patients pay the remainder as a co-pay or something?
          Sorry, my cow died so I don't need your bull

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          • #6
            Quoth EvilEmpryss View Post
            When the insurance reimbursement is only a portion of the cost of the meds, don't the patients pay the remainder as a co-pay or something?
            Yes. But sometimes insurances have an eligible cost and if what they're reimbursing is 100% of that cost, pharmacies can run into issues when their wholesaler costs too much (ex. Pts refuse to pay)

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            • #7
              Ah, I get that now. I remember seeing my Tricare bills where the doc would bill $500, Tricare would say the service was only worth $400, and then I had to cover 20% of the $400, not the $500, so the doc lost our on some of that bill.

              At least I think that's what was meant.
              Sorry, my cow died so I don't need your bull

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              • #8
                Chutzpah, right?
                In my heart, in my soul, I'm a woman for rock & roll.
                She's as fast as slugs on barbituates.

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                • #9
                  Quoth Der Cute View Post
                  Chutzpah, right?
                  Have pity on a poor orphan, Your Honor.

                  He's before the court for killing his parents...
                  I am not an a**hole. I am a hemorrhoid. I irritate a**holes!
                  Procrastination: Forward planning to insure there is something to do tomorrow.
                  Derails threads faster than a pocket nuke.

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                  • #10
                    You know, you guys have a point. It never occurred to me to ask if there was a copay. Most of our customers are in Medicaid HMO's and don't have copays. I was assuming that the number they gave me was the total reimbursement, theirs and the customer's combined. It wouldn't be the first time that they've reimbursed below cost, but I can't remember ever seeing it that far below cost.

                    (And unless the online system returns a copay due, we aren't allowed to ask the customer to make up the difference. Some pharmacies do anyway, but not any that I work for, at least when I'm there. If the loss is big enough, I generally send the customer to the chain that owns that HMO: let them rip themselves off.)

                    But even if there was a copay, it would have had to be over $100 for me to at least break even, and I'm not sure anyone would want to pay that given the availability of the generic.

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                    • #11
                      Is "PBM" "Pharmacy Benefits Manager" (i.e. insurance), with patient always going to a "bricks and mortar" pharmacy, or "Pharmacy By Mail", where they only send patient to a "bricks and mortar" location when an emergency supply (i.e. can't deliver through their own channels in time) is needed?

                      In a situation like that (I'm assuming you're the only local source - otherwise PBM should have called local branch of "bricks and mortar" pharmacy they're affiliated with), there's another option:

                      The REASON the patient had trouble finding a store that carries it might be the same reason you turned down the PBM (i.e. it being a big money-loser for the pharmacy). Instead of ending the call, PBM should have asked you about sourcing the generic (not "going over the patient's head" when they want brand name, merely research), to see if you were willing (i.e. could do it profitably) to supply that. If that comes back "Yes", PBM contacts the customer, informs them that for some reason (plays ignorant, as in "they just don't do it") local pharmacies don't carry the brand name, but do carry the generic, and asks if they'd be willing to go for the generic (which is available) rather than the brand name. If it was a "DAW" prescription, PBM would contact the doctor instead. In either case, it's a matter of "due to local supply issues, a prescription for the generic can be filled, but if you insist on brand name, you ain't getting your meds".
                      Any fool can piss on the floor. It takes a talented SC to shit on the ceiling.

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