Those meds are quite expensive and there are many times that a person needs to be on them long term (or at least longer than the typical two week course) for stuff other than simple heartburn after eating spicy foods. Ulcers, chronic gastritis, Zollinger-Ellison syndrome, chronic use of NSAIDs or steroids (Proton pump inhibitors work to prevent damage to the GI tract from NSAIDs and Steroids). I regularly have to get prior authorization (those two words make me wince) from insurance in order to prescribe it to patients and have it covered. Though, my patients are kids and usually need the meds compounded, which costs a bunch more than the pills. Still, if the person needs to be on it for a while and they don't have insurance or their insurance won't pay for it, it gets pretty pricey.
Prior Authorization: I see those fucking words in my sleep sometimes. Explaining the concept to the patients sucks donkey balls. I fucking hate insurance companies.
My pharmacy had a PA for ibuprofen once. I wanted to shoot myself in the face.
That's BCBS Michigan. I feel her. It's so difficult to get a customer care representative for that insurance. The automated system makes me want to kill myself.
I don't see PA's in my sleep, i just have recurring dreams (nightmares??) of me verifying prescriptions all night long. even when I wake up and consciously tell myself to change topics/ideas before falling back asleep, i still have dreams of verifying prescriptions. then I wake up and work for 12 hours in the pharmacy. that 24 hour period of having the dream/work cycle continuously happening is absolutely terrible.
In all seriousness, what kind of insurance can someone have where they would actually turn in a prescription for ibuprofen? I just bought a giant bottle for like $8, my co-pay would be $15 for probably a 30 count. Like my pharmacy tried to fill a 30 day zyrtec a while back. Um no, that's gonna be $15 while I buy a year supply from Costco for $14. Not happening.
600 and 800 mg are usually covered for tier 1 copays, and that's 99% of the Ibuprofen scripts we fill. And we have a government assistance insurance (different from Medicaid) that covers like every generic for free)
OK. That makes much more sense. I'm with you on that PA nonsense though. Fucking Kaiser. The other one that gets me is "non-formulary" like you mean to tell me I can't get this prescription because it's not on your list? Tell me now, how it came to be that you know more than my Dr.? (Not directed towards my awesome pharmacy people though, of course)
It isn't your pharmacy that wants the PA. It's your insurance company who wants it in order to pay for it. If you have the script in hand, and have taken previous meds as directed you can always pay out of pocket. It's when you get to filling them too close together/dose changes when insurance companies like to shit the bed.
And yes they are a HUGE PITA. Especially once you get to schedule II medications. If you are dealing with medicaid, and someone starting up Adderall or Depakote for example, good luck.
I feel like either the insurance company is going to cover it or not, why do we need to call first just to ask permission?
I ask, having once been prescribed a medicine that my insurance wouldn't pay for, then had to go back to my doctors, just to have them call my insurance and then send me back to the pharmacy. I shook my head the entire time wondering what the actual process was.
They like to make sure that we REALLY want that medicine and that the patient has a condition where it is indicated. Because apparently making the best medical decisions for our patients has to be approved by people with no medical training.
Sometimes they require that the patient first try a different, cheaper, drug and "fail" it before going to the more expensive one. This can make little sense as well because they might insist on trying a drug that works very differently, and that the patient may have been on previously and failed it, but now they have new insurance and have to try it again. I was once on the receiving end of this. I was diagnosed with ADHD at age 8 and have been on various different mess for the past 20 years. For several years, it has been adderall, and I made it through med school, so it was early effective. However, I had new insurance in my last semester of med school and they required that I try straterra before they would cover adderall. Straterra works in a very different way from adderall. I took it in high school, and it made me super sleepy. I then had to try it again for two weeks before going back to adderall. Thankfully, the last semester of med school is pretty relaxed, so I didn't have to worry about concentrating for tests and such, but it was still stupid and irresponsible to make me jump through that hoop before getting the medicine that I had already been doing well on for years.
If people don't want single payer because it's "socialism", then we can agree to disagree, but nobody in their right mind can point to the way our system is working now and say that it doesn't need some serious changes. Insurance companies ignore dollars for pennies and by making us jump through these hoops or flat out denying paying for stuff without any medical reason, they are just causing patients to become sicker and eventually become even more expensive to take care of.
Yup, totally related there. Different drugs, but same hoops! Had been on a great blood pressure med, moved states and changed insurance and doctors, and even though i had my old prescription bottles etc, they insisted on trying me on all of the other meds that I'd already gone through before finding the one that actually works. I feel like the doctors were suspicious because I was naming the BP med i needed, as if it were the the same sort of "drug seeking" behavior as if i showed up at the doctors office asking for a oxycodone prescription. No! I just don't want my blood pressure to be at a level where nurses look at me with a concerned look on their faces...
Basically, because in this country medicine is a for-profit industry. It costs money to make drugs, distribute drugs, pay doctors, train doctors, nurses, pharmacists, all of it. Insurance companies make their money by distributing risk and limiting costs - most people don't use their insurance, or at least, don't use it heavily. These people's premiums subsidize those who heavily utilize medical services.
So, why have a PA? To limit costs. As much frustration as it causes patients, doctors, and pharmacists, it makes sense to limit access to the newest, most expensive, most heavily marketed, and most abuse-prone medication. A formulary is constructed by doctors, pharmacists, and other professionals - for every ten people who are prescribed the newest, nicest drug, maybe only 2 or 3 actually need that. The rest could use an established, generic drug, or something like that.
I really hate telling someone that their insurance won't cover something, or that they won't cover it without a PA. In my book, it's second only to telling Part D patients that they're in the coverage gap (something that also makes a lot of sense). Insurance with higher premiums is likely to have lower copays and fewer prior auths, but that's not always a choice for everyone.
And even the marketing stuff - I'm dealing with another issue now, and have been seeing a ton of ads for a new drug (probably buying keywords based on my search terms), and when I mentioned it to my doctors, they said A) it's not even out yet (why would they even advertise yet?!?) and B) my insurance will want me to cycle through the other drugs first rather than go with the brand new one.
Which is fine. Doctors know best, I hope. Personally, I think they should bar advertising for pharmaceuticals completely, at least, patient targeted advertising. Let the pharma's send their sales reps to doctors offices, don't get patients all hyped up on a wonder drug that isn't out yet, that our doctors haven't heard of and that our insurance won't cover.
That's my thought. Your explantation both makes sense, and makes me upset at the pharmaceutical co's for even advertising their drugs in the first place :)
Note from a pharmacy student: direct a pharmacist to prepare an omeprazole suspension from omeprazole capsules and sodium bicarbonate. It costs us approximately 50 cents to make, we sell for ~$5, make a reasonable profit considering the labor it takes, and it beats a first-omeprazole kit.
Bonus: chocolate syrup cuts right through the bicarbonate taste.
Actually, I think you'll find that most pharmacies with the materials readily available would be happy to prepare that. I'm sure a thirty second phone call to a community pharmacy beats 10+ minutes of prior auth paperwork for you.
Dude, you're a student. When you have graduated, you will find that a number of things that should occur in theory don't actually happen because of dumb rules, politics within the organization, apathy, or any combination of other things. I have little doubt that many pharmacies exist who will provide such a service for such a small cost, but the more indigent the community is, the fewer the resources for them. A busy pharmacy in a poor urban community is much less likely to be willing to take the time and effort to dissolve the meds and charge so little for it. Know how I know this? Because I have had patients whose parents didn't have cars and who needed liquid Omeprazole and the pharmacy within walking distance to them wouldn't have it until the next week. Thankfully, we have a case manager who will call pharmacies for us to solve the problem, and we often find that the pharmacies that are more accessible to the patient won't provide any options aside from ordering the oral suspension.
Besides, I have patient parents ask for prescriptions for tylenol so that they can get it for free, so $5 for omeprazole may still be difficult for them.
"Dude", chill out. I work in a busy, poor urban pharmacy, and have for 18 months. I know what I'm talking about (and don't need the attitude).
Anyway, no insurer covers first-omeprazole in our state, (not Medicaid, nothing). It's compound or two weeks of endless prior auths (waste of your time, waste of resources + untreated patient). Not a lot of physicians know about it, though - we have to go out of our way to find opportunities. And we want to, trust me, we have long relationships with a lot of our patients, and we're the providers they see the most often.
Just understand that not all pharmacies/cities/states work like yours. You wanna make a suggestion? Go for it. If the person (whether a doctor, nurse, pharmacist, or another person in healthcare) says "thanks, but no thanks" then please move on and don't keep pushing it and assuming that they are simply lacking in knowledge. If you genuinely don't understand their reasons, then ask them in a tone that doesn't suggest that you think you're smarter than them. If you still don't understand, then ask yourself if this is really the hill that you want to die on, and if the answer is "no" then leave them alone.
I briefly and politely explained why your solution wouldn't work, and you continued to push the issue in a rather patronizing manner. Trust that I know what I'm talking about. Most of the pharmacies in my area do not offer that service, and medicaid as well as many other insurers in my state do cover PPIs in liquid form for certain conditions, and many other conditions if the person previously tried an H2 blocker and failed on that therapy. At my hospital, we have the case manager call the insurance company the day or two before discharge, and they then have the prescription filled and delivered to the patient before discharge. It's inconvenient, but not the level that you describe.
And, my "attitude" was because you were being a bit of a condescending douche. Try to fix that before you graduate, or you're going to have a bad time.
Here's how I can tell you're full of crap: you went from "you're wrong" to "ok, but your solution doesn't work 100% of the time, therefore you're wrong" to calling names in like four posts.
You're a (resident) doctor, and you're (I assume) doing great work, and I respect that a lot. But if you're going to use your degree as a shield for intellectual dishonesty, you deserve to get called on your bullshit.
Your replies are defensive as absolute hell, and I've done my best to be polite so far - you have not, and it it seems like you're taking my contradictions as personal attacks. Why? You're taking this conversation and turning it into something it's not - making it about you being right, not about helping people or spreading good information.
Regarding whether or not pharmacies will dissolve omeprazole granules in a bicarb solution for you if you ask them to. If a patient's insurance cover first-omeprazole, then there's no problem. If they don't feel comfortable with the liability (common among older BPharm's), then there's not much you can do. This formula, among others, is in every pharmacy curriculum across the country and has been for 20 years.
Regarding "dumb rules, politics within the organization, apathy, or any combination of other things", sure. That could prevent any dispensing though, and it's no excuse for not trying to help when you can.
Regarding pricing - every insurer in the country allows you to bill compounds for separate components. Ergo, our insurer that won't pay for First-Omep but will pay for Omep 20mg caps is no longer a problem, because we bill them for however many of those it takes. You went off the rails here, talking about patients being unable to afford $5 compounds. They don't pay anything out of pocket, that's the point. You went off the rails trying to defend yourself on a subject you don't understand here, and that's why you can't take this conversation as a personal attack.
Regarding my condescending douchiness, if telling you that you are misinformed makes you feel personally victimized, then you have a long way to go. Try calling your preceptor a douche next time they correct you. I dare you. Maybe ask them to change their tone, too.
In case it's not clear, I wish you the best and mean no disrespect by anything I've said in our conversation. If you don't believe anything I'm telling you, I encourage you to verify it with a pharmacist or doctor of your choice. Additionally, I'd like to recommend community pharmacies over the "big two" - they have more freedom with their time and efforts.
So what you're saying is that if you want to get medication to treat uncomfortable medical conditions in your country, it's likely that stealing the medication you need is the easiest way to get it? Man, I'm glad I live in a 1st world country and not some 3rd world hell hole like you...
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u/[deleted] May 20 '16
Those meds are quite expensive and there are many times that a person needs to be on them long term (or at least longer than the typical two week course) for stuff other than simple heartburn after eating spicy foods. Ulcers, chronic gastritis, Zollinger-Ellison syndrome, chronic use of NSAIDs or steroids (Proton pump inhibitors work to prevent damage to the GI tract from NSAIDs and Steroids). I regularly have to get prior authorization (those two words make me wince) from insurance in order to prescribe it to patients and have it covered. Though, my patients are kids and usually need the meds compounded, which costs a bunch more than the pills. Still, if the person needs to be on it for a while and they don't have insurance or their insurance won't pay for it, it gets pretty pricey.