Think of this senerio:

The owners of 3 independant pharmacies go out for dinner.  During the dinner they talk about how (for a very accurate yet hypothetical example) low MedImpacts MAC’s are compared to other insurance companies.  During the discussions they rabble on about how they cannot do business at COST + $0.75 and jointly decide to fax their contract termination letters into MedImpact.  That, right there, violates the Anti-Trust laws.

Now think of this:

CVS/Caremark (a pharmacy/PBM merger) decides that MedImpact doesnt cut the mustard.  They threaten to terminate their contract which will effect a couple hundred stores.  MedImpact tries to play the hero and refuses to negotiate, and now 300+ stores are off of MedImpacts provider list.

Three independent pharmacies get dinged for Anti-Trust behavior, while CVS/Walgreens/Rite-Aid(?) can nix hundreds of their stores without violating anything.  Tell me if that was the intent or spirit of that law.

Since we’re talking about the exploitation of the Anti-Trust laws that were made to protect citizens from such behavior; lets take CVS/Caremark.  Now a while ago we (meaning every independent in town) underwent a Caremark audit.  Now considering those auditors are paid by the infraction, and they will cancel out any prescription that was written for tablets but filled will caps (even if the medication did not come in cap dosage form) among other totally bullshit non-fraudulent-act (like the MD instead of the NP checked off), do you really think CVS gets held to the same exact standards by Caremark as us non-CVS stores?  Have you ever thought about how shady and corrupt a PBM looks taking money away from the direct competitors of their affiliated pharmacy (probably in a futile hope of putting them so far under they will sell out to *their* affiliated Pharmacy chain)?   CVS Pharmacists: Do the Caremark auditors come into your store and audit your records?  Since you’re affiliated, aren’t they just taking away from themselves? Or do you guys write off the store losses by filling ‘fraudulent prescriptions’ thereby making your store less profitable and thereby pay less taxes?  Marvel at my TinFoil hat and how its shiny!

I wonder if Medco audits its mail order pharmacy, god knows they love to audit us independants.  I wonder if all of the big PBM/Retail anti-trusters have some sort of unspoken fraternity-boy truce going around leaving the independants/grocery-outlets/walmarts on the audit chopping block.

Naaaaah, that would be in violation of the anti-trust laws that prevented 3 small pharmacies from speaking out against a dont-give-a-shit-about-you PBM.

There is an inherit problem with having zero copays for our “less fortunate” friends.  Lets look at two cases.

Mary is a 35 year old single working mom.  Her ‘baby daddy’ left her high and dry when the going got tough.  By using daycare through her family, she is able to pull off a part time job and qualifies only for food stamps.  She is not eligible for full-scope welfare due to the inherit racism that goes on within the welfare system (yeah, I went there, ignoring it wont make it go away).  She forgoes the fancy cell-phone, cable-tv, and nice car to afford health insurance for her and her baby (which shes fine with, she views insurance as a necessary expense like food).  Her copays are $50/rx.

Jacob is a 45 year old male.  Due to heavy cocaine use during his youth he has congestive heart failure and as a result is unable to work (according to him and his quack doctor).  He recieves full-scope welfare complete with food-stamps and a check every month.  He spends his day harassing his pharmacy about refilling his pain-pills early and enjoys watching daytime TV.  His copay is $0/rx.

Both Mary and Jacob bring you an Rx for some Flovent.  Mary pays $50 and Jacob pays $0 for the same Rx.  Both leave your store drugs in hand.

A week later, Jacob calls you and says he lost his Flovent.  He has spend a whole 4 min’s looking for it and demands he gets a replacement at once.  Mary also calls you a week later.  She has torn her entire house apart looking for this Flovent and is reluctant to ask for a replacement Flovent at the cost of about $175.  Jacob is upset at YOU that the insurance wont pay for it early, and Mary is upset at HERSELF for losing something that cost her $50.

See where this is going?

There is a HUGE problem with giving people medications for free.  The problem is that once something is free, people see no value to it.  Sure Jacob lost a Flovent or Blood Glucose Monitor, but because to him its free, why should he spend any of his valuable time to actually look for it vs just calling and getting another one for free.  Mary has an incentive to tear her house apart (or call her insurance company) looking for the lost Flovent because it COST her $50.  Jacob is out nothing, and Mary is out something.  Jacob gets everything handed to him while Mary busts her ass.  Both are “in need”, but their reasons for being “in need” is another rant for another day.

Mary obviously places a value on her Rx’s.  Even if shes oblivious to the true cost of the medications (and how much her insurance company pays), shes quite aware to HER cost for those medications.  Jacob, on the other hand couldn’t care less how much his lost medication has cost the state because HIS cost is a whopping zero.  Who cares if he lost every medication on his profile in an act that was entirely his fault, he’s out nothing short of the inconvenience of driving to the pharmacy and picking them up again.  He wont have to choose medication or rent, and his check wont be impacted in the least.  Mary isn’t so lucky.

Lets put it this way; by getting drugs for $0, there is no negative-feedback/punishment/repercussions for losing medication.  Medication has a net-worth of $0 to them, and they don’t give two fucks what happens to their medication because their lives are not financially impacted by losing them.  If I spend $50 on something, and I misplace it, I’m sure a shit going to tear everything apart looking for it.  Is it the same if I spend $0 on something?

Think of this next time you fill that ER prescription for Tylenol and Robatussin DM.

Sorry for the lack of updates.  Between vacation, work/life, and lack of good and funny rants things have been sorta slow here.  I intend to fix that for 2010. One rant twice monthly if it kills me.  Too many posts don’t get the awesome comments, and too little makes people lose interest in the site.  Twice a month is a happy medium.

On with the rant!

As you all well have known, we are in 2010 and we are one week past the dreaded first of the year mayhem.  If you are a pharmacist, and have not died from alcohol induced liver failure you obviously have first hand experience about HealthNet (Or their processor, CVS/Caremark) screwing up SO bad that I can’t even believe that they are still in business.

For those not “in the know”, lets set a few things straight so people don’t get confused.

• You have Medicare + Medicaid
  • You have no deductible (of usually $250 – $300 depending on plan)
  • You have little to no premiums
  • No doughnut holes (ie: the coverage gap)

Pretty much if you are on the state tit because you cannot take care of yourself, you get all the benefits of a Medicare part D plan without the annoying doughnut hole, deductibles, and screaming high copay tiers.  Nice isn’t it?  The rest of us however have the initial deductible, blah blah blah.

Now, lets rewind to HealthNet’s Medicare part D plan oh, a week ago.  At least in California, NONE of the “Dual Eligibles” (the people with Medicare AND a state welfare insurance) were flagged in HealthNet’s computer system as being on a state welfare program.  Which means that almost all of the people who should of had NO deductible suddenly got one (with a $200 copay for their Advair)!  Compound this with the usual first of the year plan changing clusterfuck and you have yourself a 2 hour hold time with HealthNets pharmacy help desk!

Oh, lets not forget that HealthNet also didnt flag generic Vicodin and Septra DS as being covered items.  So for one insurance company, we have a shitpot full of welfare-recipients pissed off at us because “we” want to charge them more than $1.10 or $3.20 AND their vicodin is no longer covered.  So whats a pharmacist to do?

Easy.  Let the fucking patient get off of their asses and take care of it themselves.  Why should we have to suffer the fallout because some computer idiot over at CVS/Caremark (which I wonder if CVS pharmacies had this problem) totally fucked up the data import from California MediCal.  Yeah, I’m a heartless asshole but I’m tired of being the human fucking shield for these PBM’s who make more per prescription than I do.  What happened with HealthNet was completely unacceptable and embarrassing.  Of course HealthNet/CVS/Caremark will continue to collect their fat ass subsidization checks from California as they tinkle in our faces with their whopping $3 above cost reimbursement.  Here me now HealthNet, unless I see some MAJOR lawsuits from you to CVS/Caremark over this bullshit, I will do everything in my power to switch my Dual Eligible patients to any plan that is not administered by you.

Oh, and just icing on the cake, I got the fax yesterday evening from HealthNet that everything was fixed.  Thats 8 days of chaos due to  a company that makes more in 1 week than I’ll see in 10 years.

Post your hateful HealthNet comments (or funny first of the year stories) and lets see if I get a response from them (and hopefully not a C&D letter).

Copays.

Probably the most confusing and frustrating concept in the pharmacy world.

The idea is simple.  You pay the pharmacy money to help pay for your drug, hence the word Co-Pay.  Like Cooperative Pay, you and your insurance company are joining forces to pay the pharmacy for the goods given to you.  If it were that simple then I wouldn’t have a website.

When I hear that I’m needed out front because a patient has a question about a copay, my GERD goes through the roof.  Not because the concept is hard, but I know that I’m going to get yelled at and blamed for something that is 100% not my responsibility, not my fault, and to be honest a whole truckload of not my fucking problem.  I’m a pharmacist, I make sure drugs don’t kill you, I don’t give a fuck about an issue between you and your insurance company.  Your insurance company says I need to collect $x, so the bill is $x.

The most frustrating (and that requires the most restraint on my part) is when people bitch that their copays got bumped up from $5 to like $15 for shit like Aciphex, Nexium, or some other drug that costs over $100.  I really have a hard time not taking their prescription back, running it out as cash, and saying “here ya go, pay that now you ungrateful stupid fuck”.  These people are stupid, and really dont get the concept that they are getting $150+ worth of medication for $15.  “I pay premiums I want my insurance to pay for all of it!” says the idiot who is getting about $500 worth of medication totaling $50 worth of copays with $200/month premiums.  You are getting MORE OUT than you are PUTTING IN and BITCHING ABOUT IT!!!! No wonder why this system is all broken.

Idiots on socialized plans (Medicare/Medicaid) are even worse, because their copays are like $3.10 which is MORE of a slap in the face when they bitch/cant pony the cash for their $200 worth of shit they probably don’t need.

Enbrel, $3.10 copay, cue the massive whining and bitching on how someone is on a “fixed income” and cant pay.  Enbrel is thousands of dollars for $3.10.  Three fucking ten.  You cant even buy a fucking value meal at McDonalds for $3.10!!! This fucking twat is whining at me for having to pay!!  I’m sorry honey, but that $3.10 is my whole profit from this Rx, so I’m not letting you pay me on the first.  Personal finance 101, make sure you have $3.10 for your Enbrel – Thank you.

I mean really, if you went to go and buy a TV at Best Buy that costs $400, and you threw a fit because you had to pay out of your own pocket $25 for this $400 TV, would you be upset if people called you stupid?  Would you be upset if the salesman said “Listen you fucking idiot, the rest of the world has to pay a whole fuckload more than you, and you’re whining about a measly $25 for a $400 product?!?”

Then there is this bullshit rumor that we set the copays.  If pharmacists could set insurance copays, then maybe the bitching and whining would have some merit.  However the HUGE FUCKING NON-SECRET is that PHARMACISTS DO NOT SET YOUR COPAYS (unless you are paying cash).  They are transmitted to us via computer and are set by the insurance company that YOU PAY (or we pay) TO PROVIDE YOU Rx COVERAGE.  Does the Taco Bell drive up teller set the price of your burrito?  NO! They punch a burrito into the computer and it spits out how much you need to pay.  Pharmacy is the exact same fucking thing, but people still don’t get it.

People want something or someone to bitch at because of their copays.  Yeah, that’s fine, but bitch at some Indian drone at Blue Cross, not me.

Here is my outline as to what could be the perfect socalized will-fail-less government subsidized medicine plan.  Since obviously this is going to be passed riding on the coattails of the H1N1 fear and panic machine, I could at least throw in my $0.02 as to how this is to be laid out.

Now before you read this, remember years past when WalMart came into town?  How they used their huge might to pretty much crush any competition in the area with “low low prices” all while shitting on their employees and being an all-around shitty store with poor service.  Now considering this government plan has the financial backing of every taxpaying man and woman in the nation (regardless if they want to or not); think of Walmart as your cushy retirement insurance plan goes bankrupt and you’re forced to enroll into a government ran plan.

The Angry Pharmacist Socialized Health Plan Solution

By: The Angry Pharmacist

http://www.theangrypharmacist.com

Here are some nice and easy (and unrealistic) points that this new government funded (with freshly printed money/stolen from the working class) health plan should have:

• No trade name drugs are covered.  No exceptions.  Prilosec/Protonix doesn’t work for you? Tough shit.  Cough with ARB? Too bad.  None of the trade name medications would be covered.  The government needs to eat its own dogfood (or practice what it preaches) and only does business with companies that drive down the cost of medication (ie: generic companies).  That expensive chemo drug not covered? Then let the government use taxpayer dollars to buy out Amgen so they can give it out for free (why not, everyone else got bailed out).
• The plan is voluntary.  If you wish to be a part of Obamacare, then you get the premiums deducted out of your gross-pay.  If you wish to have private health care, then you won’t be dinged a dime for Obamacare.  I’m not paying for all of your PacifiCare and Blue Cross plans (and your insurance premium dollars dont pay for my private insurance) so why should I have to pay for someones Obamacare?  The chances of this happening are as likely as you buying the nice bridge I have for sale.
• You get 4 doctors visits a year with no/low copay (say, $10).  Every doctors visit after that has a $25-50 copay.  Yeah, it sucks for the people with chronic conditions like diabetes and stuff, but its better than nothing.  Don’t get the unlimited text messaging plan and you can afford your doctors visits.  Don’t order a large pizza and you can afford another doctors visit.  Wait, actually becoming an active part in my health? What is this witchcraft you speak of!
• You get 1 $0 copay ER room a year.  Every ER visit after that is $100 minimum.  I’d like to see this figure raised to $250 or higher since ER is for……. EMERGENCIES!  You know why the ER rooms are so packed? People view them as “Free”.
• Since all Rx’s will be billed to the government, if you are on a maintenance medication and you are non-compliant, guess what, your premiums just went up unless YOU (not your doctor, not your pharmacy) can submit documentation showing that you were taken off of that drug, or switched to another one due to intolerance.  Whats the point of the government dumping all this cash into your doctors visits and medications if YOU are TOO LAZY to do anything about YOUR CONDITION.  Not taking your medication is just pissing away money.  No matter how many times I bitch, your doctor bitches if you don’t want to take your medicine then you can get dinged in the pocketbook.  True this can be thwarted by people just picking up their regular drugs and not taking them, but it might make a few people think twice before asking for medication they have no intention of taking.  Cue the “Waah, we don’t want the government poking its nose into our lives” as they happily promote Obamacare.  Wait, are you confused?
• If your doctor kept up to the standard of care, then unless his peers can show an act of negligence, you cannot sue him/her for 1.4 zillion dollars in a huge malpractice suit.  Lets face it, without your doctors care, you would have died a long time ago.  We don’t need your doctor running up the bill with 400 lab tests every damn office visit out of fear of getting sued if he/she happened to miss something weird.

Now on the surface, this plan looks pretty damn shitty.  However we have a fundamental problem in this country where we want privatized health-care at socialized prices (ie: Free).  Not going to happen, actually it can’t happen!  Look at MediCare and how broke it’s becoming!  No seniors bitch about Medicare (doughnut hole), because they are so (doughnut hole) happy about the coverage (doughnut hole) that it provides (doughnut hole).  Did I mention that the government had to implement the doughnut hole to keep the Medicare system from going completely broke?  Did I also mention that we just slapped Rx drug benefits on top of an already stressed system like an idiot taking a 4th mortgage out on his house to buy a boat then wondering why he can’t make the payments.  Should I just ignore the point that before Medicare part D came out, seniors on MediCare were paying cash-money for ALL of their medications and were doing just fine on all generics?  It wasn’t until the government decided to “feel sorry for them” and slap on a part-D plan that they became greedy and wanted trade name shit (all for no copays).

If health plans were cars, this would be the basement model with no A/C, manual transmission, manual windows/door locks, and it pretty much just gets you where you need to go.  This would be the ideal solution.  It gives people the basic care they need, and to be honest if they wished for a plan with more bells and whistles then some most-costly private plans could do them well.

Oh, but wait, we all want our cake and eat it too.  Mark my words, this plan will give people an inch when they want a mile, and short of the entire collapse of the healthcare system, the public will just want MORE for LESS.

I’d like my bailout in 20’s please.

Sometimes I wonder why we even listen to what patients have to say.

How many times a day are you lied to by a patient.  A patient who on the phone will tell you they “lost” their medication, but when they magically show up at the store they say they are going to Mexico for 2 months. A patient who cried how his pain pills were stolen 2 days ago, yet is in the paper today for selling his prescriptions to an undercover officer.

Heres a colorful metaphor.  You have two sparkling clean containers (the doctor and the pharmacist).  One is filled with clean pure drinking water (the message) and must be moved to the other container.  How we join them? A piece of uncleaned retired sewage pipe (the patient).  Sure, water is going to get from one container to the other, but its going to pick up a whole lot of shit along the way.  However heres the kicker, some doctors listen to what these patients have to say as the absolute truth.

Example:  Doctor calls up the pharmacy pissed as hell because the patient said that the “bad pharmacist wouldn’t fill my pain pills”.  Doctor gives the pharmacist both barrels before being fed some humble pie by learning that his beloved patient got a month supply a week ago from another doctor.

Patients are horrible translators, historians, and message carriers.  How many times has a patient told you a message they recieved from the doctor (like to stop a medication), only to have it be horribly wrong?  How many times have you had patients spout medical jargon they learned from their doctor about their condition only to have it be sorta right in a ignore-the-big-picture sort of way?  Yet doctors and pharmacists use the patient to carry messages to each other.

“Contact myself or your doctor if your lisinopril gives you a bothersome cough” turns into “My pharmacist told me to stop my lisinopril because I coughed” and “Maybe you should ask your doctor about a pain management referral” turns into  “My pharmacist said that you should send me to a pain management doctor because you don’t know what you are doing”.  The shit that patients twist and fabricate with a single grain of truth just boggles my mind, and just makes bad blood between the doctors and the pharmacists.

What kills my soul (which a lot of things do, this being one of them), is when patients have a tiny-yet-dangerous bit of medical knowledge gained through the internet or one nursing class 15 years ago.  Then the bullshit they spout actually sounds like it really did come from the doctor or pharmacist even though its completely wrong.

So how to handle this?  Easy, treat the child like he’s a fucking 5 year old, and pin a note to his/her shirt to give to the doctor/pharmacist.

In this world, there are two types of social workers:

• The ones you never see or hear about.  The one that the patient calls and they get the shit done fast.  The only time you actually speak with them is a 5 second phone call with an ID/Group/etc number and a “did it work?”.  Pharmacists love these kind of social workers.
• The social workers that are not like the above group which I will elaborate below.

Every profession has its fair share of idiots.  There are idiot pharmacists, idiot doctors, idiot bus drivers and idiot ditch diggers.  The only exception to this rule is patients, which they are all idiots.

However social workers seem to collect and concentrate the “duh”.  The social workers that make their presence known to pharmacists turn out to be the most incompetent, inept, and whiny people on the planet.  They are like like Steve Urkel (“Diiiiiiid I do that?”) of the health care world, out to do good, but end up pissing people off/making it worse in the end.  A whining contest between a crackhead and a social worker? I’ll let you guess who wins. Here is a conversation I had recently with a wonderful social worker:

SocialWorker: “Hi! I’m Billy and I’m a social worker”

TheAngryPharmacist: “Hi billy”

SW: “I got a call from John Smith who said that his Zyvox was not covered and he would have to pay for it”

TAP: “Yeah, his insurance doesn’t cover Zyvox withou-”

SW: “BUT HE IS ILL AND HE NEEDS THAT MEDICATION!”

TAP: *sigh*

SW: “HOW CAN WE GET HIM THE MEDICATION!”

TAP: “Uh, its well over a thousand dollars”

SW: “THAT IS HORRIBLE! HE NEEDS IT!”

I’m going to save you the whining that followed, because to be honest my brain had switched off at that point.  It just involved complaining about the price of Zyvox, how evil MediCal was (oh really?) and that the doctor should just be able to write for something and have it covered.  The whole concept of having a medical resident just write for Zyvox without trying anything else (or doing a C/S workup) completely eluded him.  Oh, and somehow it was /my/ fault that I wouldn’t give him the medicine for free.  Yeah, COMPLETE knowledge of how the system works.

Here is another gem:

SW: “Hi! Im Jane, the social worker for Billy Mays”

TAP: “Hi Jane”

SW: “Billy’s MediCal isn’t working, and he’s out of medication, what can we do for him”

TAP: “Well, he’s should only be out of Prevacid, he can go a day or two without it”

SW: “Well, can you fill the Rx, then call MediCal and find out when his coverage will be turned back on and bill it then?”

TAP: “Uh, no.”

SW: “Why not! HE NEEDS THE MEDICATION! HE IS IN PAIN!”

TAP: *sigh*

These two were in the span of about a week of each other. They were different social workers but I assume must either share the same lead-coated coffee cup or used the same lead-painted crib growing up.

Whenever a Medicare/Medical patient comes in and say “I spoke with my social worker about my MediCare Part D coverage” I want to bang my face against the counter.  99% of these cases end up in the patient not having coverage for a month (while one gets shut off, and the other starts the first of the following month) and suddenly it becomes my problem.  For someone who supposedly knows how the ’system’ works, they sure manage to screw things up.

Like I said earlier, there are social workers out there who are completely ninjas and are awesome at what they do, however they never TALK TO ME!  Share your funny social worker story!

As I was reading a drunken rant by The Angriest Pharmacist about unions, I started to think as to why haven’t pharmacists formed a huge union to fight the evil employers about working conditions, etc.  I know that the topic has been brought up before, but yet a union doesn’t exist.  I came to a few conclusions as to our profession:

• Pharmacists who bitch about their load, how many Rx’s they have to do, their hours, just working conditions in general (ie: not the patients like I bitch about) play the “I am/my position is in demand, so I should get work conditions of X”  Thats fine and good, but if you’re in so much demand, go and work for someone who doesn’t put you through such a shitty work environment.  I mean that’s pretty simple isn’t it?  Eventually when NOBODY wants to work for Evil Corporation X, maybe they will give you more techs/shorter hours/pee breaks/lunch, etc.  Oh, Evil Corporation gives benefits/pay of Y above everyone else, never mind.
• Pharmacists (like their Doctor counterparts) are alpha creatures.  We are the keepers of the castle of pharmacy, and we all have an opinion.  A union of Chiefs does no good if there are no Indians.
• Pharmacy is different depending on what chain/independent/hospital you work for.  Maybe your working conditions are fine (like mine).  A union won’t work if only the chain pharmacists join because some peeps who work for Target and the grocery stores are happy with their working conditions.  Is this union going to be the “High Volume Chain Pharmacist Union?”  Doesn’t work that way.  To be effective everyone needs in.
• A pharmacy union would need mandatory enrollment for all pharmacists.  Like long-shoreman, electricians, etc we would need everyone to be signed up and pay dues into this union.  We all know how much we love to be forced into things, let alone forced into things where we need to pay money.

Now lets take things into perspective.  Say all the pharmacists in the nation joined this uber powerful union.  We’ll call it the American Pharmacists Union (APhU).  Now a bunch of CVS pharmacists go to the union for help because CVS is evil and they treat their employees bad (or whatever they whine about this month).  The union leader, to show CVS that the APhU means business, calls for a strike.  Do you really think that pharmacists would listen to that?  Realistically, do you really think you’d follow the orders from some union leader (who probably has not worked a day of retail in his life, but is a damn good bullshitter) as to when you can and cannot go to work?  What if you work for a CVS that doesn’t treat its pharmacists like shit, are you going to take one (and make your patients take one) for the team for a bunch of “woe is me, 100 with only me and my tech!” whiners in a town you’ve never heard of before? Well, you’d have to.

Now APhA and the associations should be stepping up to fight bad working conditions, but then they’d have to give up the revenue for that full page add from CVS on Page 58 in the August Pharmacy Today (and a small Walmart ad on page 60).  Hell, if I didn’t know anything about pharmacy and was looking at Pharmacy Today, I would think pharmacy involves sitting smiling in front of a computer screen, and getting handed awards while shaking hands and smiling all day.  This is between the page after page of drug-company ads for another “Me Too” formulation of an already shit product or Savella, a drug made to treat a made-up condition.  Where are the crackheads yelling at you? Where are the pictures of some strung out druggie pointing her finger at you while shouting at the tops of her lungs? The happy old white people in the magazines dont exist in real life. Where are the cow-eyes and looks of “duh” or that dirty plastic produce baggy full of scummy bottles?

So we have associations for every aspect of pharmacy, why are they not taking care of the work condition problem?

I’ve ranted about how DAW-1s in the past, however a good chunk of “doctors” out there cant seem to understand exactly what it means when that “Do Not Substitute” box is checked.  I use the word “doctors” in quotes because I am also referring to people who write prescriptions such as NP, PA’s and the extremely clueless Dentists and Certified Nurse Midwifes.

In California (and pretty much every state), pharmacist have the authority (which are few and far between, trust me) to switch from a brand name drug (Prilosec) to an FDA rated generic alternative (Omeprazole).  We can do this all by ourselves!  7 years of college and a doctorate degree and doctors have trusted us with the power to switch the Brand to the Generic of a SINGLE DRUG without their all-knowing permission.  I’m sure that when this law was snuck under the doctors nose they shit all over themselves!  In fact, most pharmacists love it when doctors write the old brand name because I’d rather see “Adderall” than “Mixed Amphetaminescribblescribbledontknowwhatcomesnext”.

Now here is where the confusion comes in.  That little box that says “Do Not Substitute”, that is to prevent us from switching from the BRAND name to the FDA approve generic FOR THAT DRUG.  Idiots seem to think that we have the authority to switch from a Brand name to ANY GENERIC, we don’t.  Unless you work for a hospital, have some P&T committee overseeing you, or have some collaborative practice agreement; pharmacists CANNOT switch to a completely different drug (even in the same class) without the doctors approval.  We can just switch from the BRAND to the GENERIC of the SAME CHEMICAL.  See how simple? Obviously not.

What blows my mind is when Dentists (*sigh*) check that box and write for Amoxicillin and Ibuprofen.  So I read that the Dentist (*double sigh*)  does not want me to auto-substitute a generic for… the… generic that he/she… uh.. just wrote for…. yeah.  Certified Nurse Midwifes (uh, yeah, they can write for Rx’s and we cant, how’s that kick in the nuts towards our profession) LOVE to forbid me from substituting Docusate.. uh.. for docusate… hmm..  These people have prescriptive authorities?  They don’t even understand what that damn little box means!  “Oh, I don’t want this pharmacist substituting a generic alternative for this GENERIC THAT I’M GOING TO WRITE FOR!”  I’m sure that DDS’s and CNM’s have their reasons for needing prescriptive authority, they could at least do their profession some justice by not sloppily abusing that privilege.

The other end of the spectrum is when MD/NP/PA’s write for Lipitor and check the little idiot “Do Not Substitute (DNS)” box.  Uh, is there a generic out for Lipitor?  Why are you preventing me from switching to a generic that hasn’t even come out yet?  Do you even know what that little box does?  Obviously not.  Single-source drugs (meaning drugs that come from one source, hence the name) doesn’t require you to check the little “DNS” box because there isn’t anything to substitute them for (hence, single source)!

Then you call the doctor up and call him on it because obviously the insurance company is NOT going to pay for a brand name that costs 100x more than the generic just because he checked a little box.  What response did you get?  “Oh, the generic is fine.”  I really feel like answering “WASTE MORE OF MY TIME BY CHECKING THAT MOTHERFUCKING BOX YOU ASSHOLE!!”  Doctors can be so damn frustrating at times.  All that college and they can’t understand a simple concept like the DNS box on their Rx pads.

Don’t get me started on OB/GYN’s and checking that fucking box on prenatal vitamins or iron tablets.

If the state allowed us to switch a non-covered brand to a class-equivalent brand/generic (meaning switch the whole drug to another in the same class) then I can see them checking the box for everything.  However we can’t switch drugs, so checking that box just because you have no idea what it means just makes yourself look like an idiot.

This has been a Public Service Announcement by The Angry Pharmacist.

I’ve ranted about this. JP has ranted about this in Drug Topics. However some big-chain pharmacists *ahemWalMartahem* don’t seem to get the idea across.

You see, I really hate to bug pharmacists for copies/transfers.  Usually I’ll call their confusing little voicemail system, hit the proper combination of buttons to get to the “Voice Mailbox for New Prescriptions” (that is reserved for doctors), and kindly give all my information, what I need, my fax number, etc.  I figure that the pharmacist will check the mailbox for any new prescriptions, get my request, and fax over my copy.  Works great for Walgreens, Rite-Aid, CVS, etc.  The pharmacists like it too since I’m not bothering them and they are already in the ‘write down stuff’ mode when they check the voicemail.

Note to all of you out there:  I tried to do this with WalMart.  I waited 3 hours with no response.  I called WalMart and was left on hold for over 10 mins.   My tech called on another line and said “My pharmacist has been on hold for over 10 min, why are you answering my call?”.  I didn’t even get the common fucking courtesy of “The pharmacist is tied up, can he/she give you a call back”, “What numbers do you need and your fax number and I’ll give them to the pharmacist”, or even a “We’re really sorry, it’ll just a little bit longer”  I was just left on hold for 10 long non-intterupted mins with nothing but dead air to listen to.  I fucking hate being on hold because not only do I hate working while cradling a fucking phone on my shoulder, but its $1/min wasted for the store and just tells me what kind of outfit I can expect when someone does pick up the phone.

The response when I finally got through to someone (15 min hold time total by the timer on my phone): “You shouldn’t leave copy requests there, you should just call us.” *blink blink*  For once, I was at a total loss for words…  Yeah, after I was left on hold for 15 mins he said that…  Please tell me that I’m not the only one who thinks that what this pharmacist just said the completely wrong thing to me.  I’m sure glad I wasn’t a doctor leaving a new prescription on that voicemail system since it would be 5 hours before it would be filled!

Is this really how we treat our own?  Seriously, what the fuck.

Listen, we’re all busy.  We all have shitty patients we have to deal with, shitty doctors offices, and shitty staff.  We are overworked and stressed.  However that’s no excuse to shit all over someone who is in the SAME boat you are in and sooner-or-later you’ll need a copy from them.  If you didn’t get the whole idea about professional courtesy from my previous rant and JP’s rant, then obviously you need to go work in a mail-order joint and get the fuck out of retail.  I don’t give a fuck what your ‘corporate’ office says, or what your district manager or store manager says.  You know those people who boss you around in ‘management’ positions?  They couldn’t cut it in the trenches, thats why they have to boss you around.  If your manager actually works retail, they won’t bitch at you for letting that whiny crackhead bitching up a storm wait a whole 2 more mins longer while you give some professional courtesy to someone else who has that exact same crackhead bitching at them on the other end of the phone.

Unlike how I act on here, I choose to take the high road.  I don’t “lose” copy requests from pharmacies that are slow/unresponsive to copy requests.  I don’t get even with them.  I don’t fax over reams of pure black pages in the middle of the night to burn out all of the toner in their fax machines nor filling up their voicemail with me singing drunkenly in their voicemail at 2am on weeknights.

In the long run, its not worth trying to get even by petty things, real retail pharmacists are better than that. What really counts is when you’re at that fancy CE dinners (with the free booze), and after 4 gin’s you meet that WalMart pharmacist from the store that is giving you grief.  As you look him/her straight in the eye, you introduce yourself and say “Your store is the shittiest store in town for sending out copies.  I send copies to you within 10 mins, and you send them hours later if that.  That’s really bullshit, I hate calling your store, but your lack of service brings a ton of business to mine so I’m forced to.”  Then you see the reaction.  You see the stammering, the excuses, and with all that Gin in your system you can get that good concerned/blank look.  Blowing up on the phone at the person won’t do a bit of good, but in person, face-to-face is when you can really nail someone.  And after all of the excuses and apologies that fly in your direction, you just shake your head and walk away disgusted leaving them feeling like shit.  One of these days I’m going to stop by the DrugMonkey’s store and use this on him, then we’re going drinking afterwards.  I know he’ll want me to subsidize his bar-tab.  Some things never change (I kid, I kid!)

I’m prepared for the onslaught of Walmart pharmacists now who read this site commenting with “You’re right” or “You are so wrong I’m never reading this site again”.  You know, thats life, sometimes the truth hurts and it takes someone to publically blast the lack of professional courtesy that some chains have (plus you all get off on how awesome and blunt I am).  If you give this letter to your boss/DM and they say “eh, whatever” vs “I’ll look into this”, doesn’t that say right there what kind of company you work for and how they view pharmacists?

Walmart – $4 prices, $4 service.