Plan Limitations Exceeded

How many times a day does that message pop-up on your third-party rejections screen? Usually it happens when you are trying to submit a claim for a 90 day supply when the plan only pays for thirty. Or when the prescribed dose takes the medication over the plan's daily limit, which is sometimes resolved with a quick call to get the override.

Other times it pops up when a maintenance medication is trying to be filled at the local retail pharmacy and the patient's plan requires mail-order after the first two fills at the local pharmacy. I get that. I expect that..... in March or April.

Not on January 2.

I had that message appear on one of the first prescriptions that I filled last Saturday. And since then about two scripts per day. A little bit ridiculous.

Oh wait, I forgot to tell you what the secondary message said:

-Please have customer call CVS Caremark 888-769-9030

Now you know what's going on. Even though my pharmacy is contracted with CVS Caremark, I'm only allowed to fill one prescription for my patients, then I have to tell them that they need to either go to the CVS that is two miles away or start mail-ordering. Somehow this doesn't seem right to me.

But stuff like this has been going on for years. And it's not exclusively CVS Caremark.

This is what happens when insurers of prescription medications are permitted to be providers. They set up little rules that force the patients to use them. Want to use a non-preferred pharmacy? No problem... copay will be doubled... if they allow you to use the non-preferred provider.

A year or so ago I called an insurance company to see how I was being reimbursed for a particular medication that I felt our pharmacy was being low-balled on. I wanted to know which formula was being used.

Federal MAC-plus?

AWP-minus?

AMP-plus?

GEAP?

I think it was the insurance company's MAC-plus list, because I couldn't get the math to work out using any of the other formulas that were included in our contract. I asked for a copy of the insurer's MAC-plus list to be emailed to me.

No.

Proprietary information.

So here's where we are. Insurance company (who is also a provider) gets to pick and choose which reimbursement levels the contracted pharmacies receive. They won't let us see the list of medications that are on each list. We just have to trust them.

I wonder if the reimbursements are also based on NCPDP numbers. Maybe the locations that are affiliated with the insurer get a little bit higher reimbursement levels. Competitors get a little bit lower levels. Hmmm.... I wonder how the insurance company's profits are doing?

Just some things to think about.

* * * * *

This is not an indictment of CVS Caremark. They are the national-level player that everybody can identify with. I personally think these practices occur more frequently at insurance companies that operate on a local/regional level where they hold a significant market share.

APhA claims MTMs as a win for pharmacy

The APhA is basically claiming a victory for having MTMs included in both the House and Senate versions of the health care bill. They claim a new mission for the profession grounded in MTM (this from their Top 10 News Stories of 2009 segment of the January 4 pharmacist.com FocusXtra email).

Well I've been making a few calls and sending out some emails to see how easy it is to get signed up as a medication therapy management provider with the Medicare D plans that operate in my state (Ohio). I'm doing this because my current employer is not really interested in the whole MTM-thing, which I can understand because at my previous position we had two or three MTM cases over a three year period. Not exactly a money-maker for the drugstore.

I'll let you know the results of my inquiries.

As it is now, the APhA seems as connected to the the real practice of pharmacy as my yellow lab who is sleeping on the floor right now. I've got an email in to them as well. Since my previous communications with them have been met with a lack of response, I'm expecting the same level of concern from them about real pharmacists as I have seen in the past.

In the meantime, if you work in a pharmacy that has actually been able to make MTMs a viable business venture let me know (government clinics and academia are not viable businesses). I would love to know how you are doing it. Shoot an email off to ericrph@msn.com .

If you are from the APhA, email me as well. We're all trying to advance the profession.

The apple doesn't fall far from the tree

Not too long ago I came home from work after a 10-6 Sunday at the pharmacy. Wasn't a difficult day, but it felt good to be home.

My fourteen year-old son shared something that had happened to him at church earlier in the day. I should mention that our church averages about three thousand people per Sunday. It's the largest church in our area. Very easy to miss people in the crowd.

Anyhow, between services a 70+ year old woman walked up to him and asked him if his dad was the pharmacist who worked at XYZ Pharmacy.

My son answered yes, wondering where the conversation was going.

She then proceeds to inform him that her shoulder had been hurting for several days and asked my fourteen year-old what she should take.

Now my wife is used to questions like this. So are the spouses of our physician friends.

But to an eighth-grader?

He asked her what she had tried (nothing) and then told her Tylenol or Motrin before running off with his buddies.