Behind the Counter: Adventures in Dispensing. Episode III.

[Shalom]

The third in an irregular series of posts, chronicling the wacky things happening in an average pharmacy (i.e. mine). From memory, too busy to post from work (plus don't want the boss reading over my shoulder).

Fill What I Want, Not What I Write

First, a bit of history. The Zithromax Tri-Pak is the original version, as found in Europe: 500mg once daily for 3 days, comes on a card with three tablets marked Day 1, Day 2 and Day 3. Thing is, azithromycin usually takes 5-7 days for any effect to be noticed, and 10 days for the full effect; it keeps on working even though you stopped taking it 7 days ago. When it was released in the USA, the manufacturers (Pfizer, if I remember correctly) were afraid that we Americans would be too impatient to wait, and would be on the phone with the doctor on Day 4, demanding a refill, so they came up with the Z-Pak, this being six 250mg tabs. Take 2 on day 1, then 1 daily for the next four days, and by Day 5, you'll already notice an effect. It works just as well if you take 2 tabs daily for 3 days and then wait.

So I had an e-script came in today. Zithromax 500mg Tri-Pak. Quantity: 30. Sig: Take 1 tablet as directed.

Why in earth they want 30 tablets? That's ten Tri-Paks. Plus, most doctors around here don't use the Tri-Pak, unless they want the patient to take it for 5 days instead of 3. (Which means we have to break a pack, as we don't stock them loose.)

So we call the doctor to find out what the hell. Turns out, he never even heard of the Tri-Pak. Has no clue how it got on the e-Rx above his electronic signature, much less the quantity of 30. Wants us to fill the regular 250mg Z-pak, 6 tabs for 5 days.

Another e-script today: B&D Alcohol Swabs. Sig: Take 1 pill three times daily.

You know, when electronic prescribing came in, they promised us it would eliminate prescription errors, because everything would be totally legible. Sure, totally legible and totally wrong.

That doesn't exist. Stop asking for it.

Patient comes in asking for Vitamin C oil. I tell him there's no such thing, ascorbic acid isn't even fat-soluble, and he's probably looking for Vitamin E oil instead. He insists the nurse told him to get Vitamin C oil for putting on a healing wound so it wouldn't scar. This is a legitimate use for vitamin E oil, which I went out to the aisle to show him where it is. He keeps saying Vitamin C oil, and I keep correcting him, but he eventually buys the correct stuff.

That doesn't exist either.

Another patient, a half hour later, comes up and asks me for Vitamin O.

More irrational price hikes.

Econazole cream, an antifungal, in the 85 gram size, just went from $11.25 to $347.76. Why? Same reason the dog licks his you know what: because he can, son.

[sms001]

Another e-script today: B&D Alcohol Swabs. Sig: Take 1 pill three times daily.

Plot twist: Do Not Take With Alcohol.

from $11.25 to $347.76.

Will their (or any pharma company) reps fill you in on any sort of real reasoning behind these things if you ask? 'cause I gotta imagine that you field a lot of questions about such things.

[wolfie]

Needless to say, insurance companies won't recognize the price increase, so your reimbursement will stay at $11.25. If you don't want to lose a pile of money on each tube dispensed, you'll have to face the wrath of customers when the medication they need is "permanently out of stock".

Just curious, but when insurance companies reimburse at FAR less than the cost of the medication (after all, when they need to keep premiums down to a forearm and a shin while still paying for the CEO's yacht, SOMEONE needs to make up the difference), why don't pharmacies only sell those medications on a "customer must pay upfront and submit paperwork to their insurer for reimbursement" basis?

[Geek King]

That doesn't exist either.

Another patient, a half hour later, comes up and asks me for Vitamin O.

Wasn't that what they used to prescribe to treat "female hysteria"?

[Shalom]

Here's another one.

Flucinonide ointment. Last month was $38.63, now is $211.83.

Of course the reimbursement is still $35.23; they didn't even keep up with the last price increase. So we lost 3 and a half dollars even at the old price. Now? No way in hell am I dispensing this. Let him go to the three-letter chain or somewhere.

Oh, and the voltage in the store (nominal 115 here) has been bouncing from 100 to 130 volts all afternoon, with a peak at 150 (which made all our fluorescent lights start flashing rapidly) to a trough of 83, which made my UPS kick in and everyone else's computers shut off. I called Orange and Rockland, they sent a guy here, but said he's overhead only, and the underground guy should be here in an hour. Hope we don't lose it altogether. Our own electrician suspects a loose neutral, but he can't do anything until O&R's guy gets here.

Whoa. 147 now. That's gonna burn stuff out.

ETA: Been stable at 118 for fifteen minutes now. I guess they fixed whatever.

ETA: Not so fast. They had to pull the main switch a couple times. Both times they at least gave us adequate warning, so we could shut down computers, etc. Unfortunately, the emergency backup lights didn't work, and we were left in pitch darkness.

Oh, and now the latest shortage? Zinc oxide ointment. The 16-oz size ($4.25) is backordered: "vendor experiencing delay in production". Of course I can still order an ounce tube for $2.10, or about 8 times the price per ounce.

F*** me.

[Slayer]

Just curious, but when insurance companies reimburse at FAR less than the cost of the medication [...] why don't pharmacies only sell those medications on a "customer must pay upfront and submit paperwork to their insurer for reimbursement" basis?

A patient who won't pay an increased copay (ex. the amount not covered by the plan), will likely not pay the newly increased cost upfront. Most insurances do pay less than cost because that's what a copay is for (here, anyway). The eligible cost considered by the plan can be a deciding factor.

I'd rather use online billing to see what the balance is than get surprised and screwed over with manual submit.

[wolfie]

A patient who won't pay an increased copay (ex. the amount not covered by the plan), will likely not pay the newly increased cost upfront. Most insurances do pay less than cost because that's what a copay is for (here, anyway).

But in cases like this (I'll use the Fluciononide example - cost went from $38.63 to $211.83, reimbursement $35.23), even with the old price the copay would barely make things up to the medication cost, not covering the pharmacist's time. Which would the store be better off with: Customer, on hearing they need to pay the full cost up front and claim reimbursement from their insurer, says "Screw it, I'll get this filled somewhere else", or you make the sale and lose a 3-figure amount on it due to the inadequate reimbursement?

[Slayer]

Here, you don't have to dispense it if you don't want to. Saying no or explaining why from the start is better IMO than trying to get a patient to pay upfront knowing full well that they won't get their money back. And sadly, cash prices are often higher than a price billed through insurance. It's such a mess trying to get that sorted out.

You'd also need to explain why their billing was DDC before but now it's manual submit. And chances are, they're going to call their insurance to back up what you're saying while they're still in the store. It's just quicker to be honest.

[Sapphire Silk]

Will their (or any pharma company) reps fill you in on any sort of real reasoning behind these things if you ask? 'cause I gotta imagine that you field a lot of questions about such things.

A lot of times it has to do with scarcity. Either the manufacturer can't get the ingredients, so cost goes up. Or the manufacturer decides he'd rather make Blockbuster Pill for Penile Enhancement that most men really don't even need, instead of vital life saving drugs like Narcan to reverse opiate overdoses.

Or a middle man buys up all the stock, creates scarcity, and ups the prices.

----

I was in my favorite pizza place for lunch today when I overheard a most interesting conversation.

A woman decided to call her pharmacy about a refill while she was eating. She spoke very loudly and I could hear every word she said.

Loudmouth: Hello? Yes my name is Loudmouthed Fool, and my date of birth is January 1, I'molderthanIlook. I'm calling about my benzodiazapene prescription. Yes, last time I filled it you didn't have enough and you gave me a partial refill. I need to get a refill today. No, I'm in North Carolina today, but I want the refill available today. My husband will pick it up. Well, this is unacceptable. You should have it by now. Fine, transfer me to the X street store, it's closer to my husbands job anyway. Say, can you tell me why this medicine has gotten so hard to get lately? And it's getting too expensive. Why is the price going up? Fine I'll call back later.

Me: I just got enough information to steal your identity, lady.

[Dreamstalker]

If I was savvy enough to make use of any of the info I've overheard in public/on mass transit...I wouldn't be in the country anymore and/or you'd see me on American Greed. I've even heard people giving their SSN...yelling it of course because the train is so noisy

[Shalom]

We just got a call from our secondary wholesaler, alerting us that enalapril and lisinopril are going to be going up in price this weekend.

Why? this shit costs pennies. PENNIES!!

At least this time they let us know before it goes up, rather than giving us a nasty surprise when we go to reorder.

ETA: Now I went to order Ultracet (tramadol + APAP) and find that the old item numbers are invalid, because tramadol is now a scheduled substance on the Federal level, and they had to repack it in bottles with the C-IV logo on it. Of course some (though not all) of the manufacturers took the opportunity to raise the prices by 33%... sigh.

[Sapphire Silk]

We just got a call from our secondary wholesaler, alerting us that enalapril and lisinopril are going to be going up in price this weekend.

Why? this shit costs pennies. PENNIES!!

Great. Just peachy. I take lisinopril, and it works great.

I just got a 3 month supply. Assuming my pharmacy has the same issue, think it'll come back down anytime soon?

[Shalom]

Well it looks like this time at least was a false alarm. It's still less than 5 bucks for a bottle of 90 of lisinopril at the wholesale level, and less than 15 for enalapril, so you can relax. For now.

Of course if you pay cash at a chain pharmacy, this may have no bearing on what they actually charge you for the stuff ... I went once to a chain, a place where I'd worked, because I was out of my losartan (which I've since stopped taking, was worsening my tinnitus) and needed to pay cash for one fill. (My insurance is through my wife's union, which has mandatory mail order. I am opposed to this for philosophical reasons, so I pay cash at my own store, but I wasn't going to be on shift for another couple days.)

I brought them a prescription, but of course it didn't go through at retail. They wanted to charge me $110.00 for 30 tabs at cash. I told them they were nutz, I could get 90 tabs from my wholesaler for less than $10. They said, you worked here, you know how it works.

I asked them if the minimum price for any cash ℞ was still $10.99? Yes, it was. How many tablets could I get for $10.99? Three. Fine, gimme three, I'll get the rest when I go in to work on Monday.

I've got some more ranting to do, but I'll open up another thread on that one.

[Sapphire Silk]

I paid $36 for 90 tab of linsinopril 10mg about a month ago. So I'm still paying a hell of a markup, but I can live with this one.

[EricKei]

I take Lisinopril...so I'm really glad I kept on reading after that initial post about it

Thing is, reasonably enough, I'm also on HCTZ -- and the prices I've paid on them have varied wildly in the past year, due to a bit of weirdness, as such: The doc has me on something like 40mg Lis (up from 20 at prior visit), 20mg H...So, she prescribed me 40L, 20H as separate pills -- used to be a combo pill, $10 for 90. With them separate, this became $10 for 90 H and somewhere around $40 for 90 40mg L pills -- So she did some research for me, and discovered that 20mg L pills were $10 for 90. In other words, the 40mg's were NOT on the approved generic discount list, but the 20's are. She was willing to work with me (my income is...less than ideal), and got me a hybrid 20mg/20mg pill and a 20mg pill, both of which were covered, so I end up spending $20 every 3 months instead of $50+ for the exact same medication (in addition to synthroid and metformin).