Can a pharmacy profit from gouging patients without insurance?

It just shouldn’t be hard to get a refill on the medicines I’m taking:

  • phone the pharmacy to refill prescriptions
  • show up the next day to pick up refills
  • pay

Simple, right?

Note that this is about my old pharmacy, not the new one.  For quite a while the pharmacy had been having difficulties, which is why I never trust the pharmacy.  Between the distance and the frustrations I had dealing with them, I’ve wanted to switch for quite a while.  Almost every month I’d come home and write another rant about what had gone wrong – but usually leave it in my draft folder.

Once I phoned on a Monday morning, spent ten minutes punching prescription numbers into the automated system, and expected things to be ready the following day.  There was certainly no reason that my refills shouldn’t have been ready, but none of my medicine was ready when I attempted to get my order on Thursday.  None of them!  The pharmacist was as puzzled as I was; the order was there, it just hadn’t been filled.  They were out of one of the meds, so the tech had decided not to fill anything (and not make sure the missing med was ordered, and not notify me, either).  I had to drive an extra fifty miles the following day to try again (after calling first).

The next month I phoned to verify that my meds were ready before making the drive to town.  I try not to bother them with phone calls because I know they’re busy, but they kinda brought it on themselves.  Good thing I called, too, because they were still waiting for the refill approval from my rheumatologist.  How enlightening, when I phoned the doctor’s office, to discover that the approval had been done a couple days earlier.  It wasn’t a case of the pharmacy’s word against the doctor’s office.  After faxing back to the pharmacy, the nurse followed their office policy and filed the fax confirmation in my chart (apparently some pharmacies have a reputation).  I’m sure (from reading pharmacy blogs) that sometimes the doctor’s office doesn’t get back to the pharmacy in a timely manner, but not this time.  The screw-up was entirely on the pharmacy’s end.

Then there was the time my husband agreed to save me the driving and stopped at the pharmacy for me when he was in town.  He’d gone to the pharmacy for me once before and they overcharged him, so I sent him a very clear list:

Can a pharmacy profit from gouging patients without insurance?

Image his surprise when the total rang up at $102!  They hadn’t run the Enbrel card (it seems to depend on which tech is working whether or not that gets done).  They fixed the Enbrel, but nothing else. Rather than figure out why it cost so much (since it had already taken too long), my husband paid $45 for something that should have cost $5.

That is highway robbery.  My lowest drug co-pay is $10.  The only time a prescription costs me less than $10 is if the drug costs the pharmacy less than $10 and they can still turn a profit charging less.  According to the pharmacy, the insurance company, and the plan administrator, the pharmacy is still entitled to the full $10, but they have the option of passing the savings along to patients.  This means, unless I’ve completely lost my mind, that the pharmacy can make a profit by charging $5.10 for feldene, but they gouge an extra $40 out of people who don’t have insurance.

If we ever lose our insurance, you can bet I’ll be shopping around for my meds based on price.

WarmSocks blogs at ∞ itis.

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  • ninguem

    And they want to do disease management.

    • jsmith

      Three rings and it’d be a full-on circus.

      • http://www.theangrypharmacist.com TheAngryPharmacist

        People in glass houses shouldn’t throw stones.

        Pharmacists go to the doctor as well.

    • Pharmer Joshua

      And medical residents shouldn’t be allowed to prescribe out of school. They kill people. Most of my interventions safe people money, save hospitals money, and protect patients from poor prescribing habits. I would put my disease management skills (not diagnosis) skills up against any PCP.

  • PCP MD

    “they were still waiting for the refill approval from my rheumatologist. How enlightening, when I phoned the doctor’s office, to discover that the approval had been done a couple days earlier.”

    I bet I know which pharmacy this was, a big one that starts with W. I have called in rx in front of patients, only to have the patients told at the pharmacy “The doctor never called it in” Talk about throwing under the bus. So now with that pharmacy I only fax. I will call in pts rx anywhere else.

    • http://warmsocks.wordpress.com/ WarmSocks

      I haven’t been impressed with the big W. It was at a big pharmacy chain that uses fabulous flat, red prescription bottles ;) Oh, that everyone would change their bottle shape & make the labels so easy to read. I have since changed pharmacies, and have been very very happy with the new place.

  • http://persnicketyrph.blogspot.com Jonathan Lloyd

    Not sure who you can believe. I used to work at a pharmacy (beginning with W). Many times customers would come in and wonder where their Rx was. “Not called in,” I’d say. “I was right there when they called you!” they’d say. Uh, huh. Well, being the only pharmacist on most days I could categorically assure them that they had not called. They probably called somebody. But not the right pharmacy.
    Couple of things as well. No pharmacy makes money selling something less than $7. That is a loss-leader. Rite Aid did a study about fifteen years ago showing that filling an empty vial costs $6. By now it’s probably more like $8-$10.
    Another thing: MD’s have no concept of how complicated insurances make filling a prescription. If we have to train a tech or two (which happens about every other week because nobody can hack retail) we have to start all over again with a very difficult training period. Long learning curve. Why make things complicated? Less fillable Rxs=less billable rxs.
    I am confident that the pharmacy you were at was over-worked, under-staffed, over-stressed. They were not ripping anyone off. Mistakes were made, certainly, but those were mostly caused by other factors than the ones you are pointing out.

    • http://warmsocks.wordpress.com/ WarmSocks

      I’m familiar with the wrong numbers when people are trying to phone the pharmacy. My home telephone number is quite similar to the local pharmacy, and we often found messages for the pharmacy on our answering machine. Our solution was to add, “If you’re trying to reach the pharmacy, that phone number is ###-####” on our outgoing message.

      As for the cost of filling prescriptions, you’re saying something different than pharmacies and insurers have told me. Could be, though. They definitely appeared understaffed all the time.

  • jessica

    For every poorly run pharmacy, there is a poorly run doctor’s office, a poorly trained nurse, etc etc. I choose to believe this is an exception, because I’ve had nothing but positive experiences at the majority of pharmacies I have used, even the chains. Somehow they manage to take the time to tell me about my medicine in between phones ringing off the hook and customers yelling at them for ridiculous reasons. The same goes for the doctor who spends an extra 5 minutes with me even though he is overbooked to make sure he answers all my questions.

    Let’s stop pointing fingers and complaining and instead recognize those who are doing a great job in spite of the external circumstances around them. It is exhausting and not constructive for anyone.

    • http://warmsocks.wordpress.com/ WarmSocks

      I am 100% in favor of recognizing a job well done.

      On the other hand, sometimes you can’t just let errors slide. When someone persists in repeating an error, it’s important to speak up. I don’t want to pay $102 for something that is supposed to cost me $37, and I shouldn’t have to deal with this type of mistake month after month after month.

      If I was paying cash (instead of having insurance), I would be extremely unhappy to hear that the pharmacy was claiming that it could make a profit by charging $5, but they chose to charge me an extra $40. According to another commentor, it sounds like that might not be true, but that is the claim that they have made. Repeatedly. If I was a cash customer, I would check prices at every pharmacy instead of assuming that costs are similar everywhere.

      Some patients are happy to know that they might be able to save money. People don’t always look at the cost when they go to the pharmacy. They just swipe their credit card and figure out how to juggle money to pay the bills when they come due. When you know that sometimes errors are made, then you can take the extra 30 seconds needed to make sure that everything was rung up accurately. Don’t just check the meds; check the price.

      • Pharmer Joshua

        Um, cash patients get screwed across the board, from the doctor’s office all the way to the pharmacy. How do you think everyone tries to recoup costs after getting screwed by Medicare and private insurance companies that follow Medicare?

        You do realize that you aren’t just paying for the product, right? You are also receiving the expertise of a health care professional that went to school for 6-8 years, had much more pharmacology and therapeutics than an MD, and is much more accessible than your PCP. You have a choice of which pharmacy to go to, so switch to mail order if you aren’t happy and don’t want access to a pharmacist.

  • http://www.aneurysmsupport.com/ Mike

    I suspect that the issue is often with the pharmacy technicians. Very often these are young people, with little to no formal training and who often lack the necessary work ethics for this type of work. As many work for, or near minimum wage, it does not always attract the best employees.

    • http://warmsocks.wordpress.com/ WarmSocks

      You are probably right. I finally learned the techs’ schedules so that I could plan to pick things up when the competent tech was working.

      • http://www.aneurysmsupport.com/ Mike

        Sadly, I am afraid that is what you have to do in many businesses nowadays, the work ethic is fading fast. I should probably add a disclaimer to my post to let the better techs know that I do not automatically lump them all together. There are, I know, some competent and hard working techs, even a few young ones, who make a conscientious effort to do a good and accurate job. There have even been a couple at the big W-M, who went out of there way to help straighten up a problem for me and get my medication refilled on a timely basis.

        I miss the local pharmacies. Even out in the Midwestern sticks where I live our last locally owned and operated pharmacy has closed, surprisingly, not due to competition from the big chain stores. He just decided to retire a bit early and pursue other interests. I recall one time when he, learning that my mom would not get off work in time to pick-up her BP medication, dropped it off to her on his way home. He was not asked to do this, nor did he charge for this and I doubt that she was the only person to experience such service from him. Even more surprisingly, this guy somehow managed to keep prices in line with the big guys, occasionally even a bit cheaper. No idea how he did it but suspect that his profits must have really taken a hit.

        • Pharmer Joshua

          Yeah, that guy was not making much of a profit. Until chain pharmacists stop bowing to the salaries of the big chain pharmacies that charge for prescriptions below cost, then people will never pay for the expertise of a pharmacist. Most pharmacists fail to realize that they are only there so that the customers have a chance to pick up a gallon of milk or a high profit margin product along the way to the pharmacy.

      • Pharmer Joshua

        I would put pharmacy techs ahead of the people working in doctor’s offices. Those are the office assistants and nurses that can’t pronounce medication names correctly, but they can sure weigh you on a scale pretty well. I’ve busted two RN’s and 3 assistants for calling in fake RX’s since I started practicing as a pharmacist.

        Either way, you have more choices for a pharmacy than you do for a PCP. Physicians are protect by anti-competitive licensing and prescription authority. And they don’t like their performance to be measured.

  • Christine

    Those co-pays are unbelievably low. Do you have any idea how lucky you are?

    • http://warmsocks.wordpress.com/ WarmSocks

      Yes, I know that I’m very fortunate to have fabulous insurance coverage. Unfortunately, my company is planning to change insurance plans; drug copays will increase, office visit copays will increase, annual deductible will quintuple. But at least I have a way to reduce my out-of-pocket expenses.

      • http://www.aneurysmsupport.com/ Mike

        Recently my insurance company decided that they would no longer cover one of my medications, the most expensive one, unless I ordered it through the mail, which sounds like a major pain. No warning on their policy change and I found out at the pharmacy when the insurance rejected it as the clerk was ringing it up. They offered 4 generics they would cover but not certain what my doctor will think of this.

        • http://warmsocks.wordpress.com/ WarmSocks

          Argh! I’m lucky in that my doctors prescribe generics first, and only go to the expensive stuff if the generics aren’t effective. Good luck.

  • solo dr

    In my area the other W has great prices and service. Two large national discount supercenter stores now offer $4 monthly and $10 90 day supplies of many popular generic HTN/Chol/T2DM generic meds to patients with or without insurance. Many of them meds are cheaper locally than using the difficulty mail order phamracies.

    • Pharmer Joshua

      That’s great! Just don’t complain if the customer service isn’t perfect. You get what you pay for.

  • imdoc

    Just imagine what it would be like buying groceries if we had a third party payment system. We need to go back to a system in which the consumer (patient) pays the one providing the service (pharmacy), then dukes it out with the intermediary who charged the premium and agreed to pay the bill. Chances are the prices in the pharmacy would become much more transparent and also truly competitive.

    • http://warmsocks.wordpress.com/ WarmSocks

      I agree 100%
      I would love a return to the day that patients paid a transparent price, and were then reimbursed by their insurer.

      • http://www.theangrypharmacist.com TheAngryPharmacist

        All of us would like that as well. Unfortunally “if its not free, its not for me” is the pharmacy mantra now days.

  • http://www.theangrypharmacist.com TheAngryPharmacist

    Pharmacies make only about $20 off of that little Enbrel card and have to stock/special order a PITA-to-return refrigerated product that costs $1200-$1500. Give me $1500 of your cash and in a month’s time I’ll give you $1520 back.

    Quit bitching about your copays. You know who foots the bill for your little Enbrel card? People who don’t qualify for the Enbrel card. They have a right to bitch. If I got $1500 worth of medication for $5, $10, hell $100 I’d drive an hour with a smile on my face because I’m making over $500/hr.

    • http://warmsocks.wordpress.com/ WarmSocks

      Perhaps you misread. This post does not complain about copays. My complaint is about being overcharged.

      You claim that the pharmacy’s cost for Enbrel is $1200-$1500. The cash price for that med is $2266.99. I’m inclined to see this as additional evidence for price gouging.

      There’s really no reason for you to stock Enbrel all the time. When people order their refills, then you can order what you know someone actually needs.

      • Rxcounter

        Except that it’s not always a refill, and my training was sorely lacking on the ESP front. Your approach to inventory management is the quickest way to be out of everything and getting fussed at. If a pharmacy isn’t diligent about managing inventory and keeping on-hand what gets dispensed regularly, things come to a screeching halt and the staff catches the flak. At best, we can order for the next day and at worst heaven-knows-when if it’s on backorder. See my bottom post for a quick primer on the economics of the situation.

      • http://www.theangrypharmacist.com TheAngryPharmacist

        Usually Enbrel takes a few days to order. Its a really expensive refrigerated item that used to be dropshipped directly from the manufacturer.

        In that case, “calling a day ahead of time” would leave you Enbrelless when you came in to pick up your other meds.

        When I initially commented the image didnt show up of the strength that you were on, therefore I was giving you the ballpark bargain basement price for the 25mg.

  • http://www.theangrypharmacist.com TheAngryPharmacist

    And Kevin, seriously? Gouging? You couldn’t think of a better title? It’s not like she was charged trade-name prices for generic products that cost pennies.

    Lets talk about much the labs charge, or how much you bill for office visits before the insurance companies MAC you down to your base cost like they do us.

  • http://www.iwanttobeapharmacist.com/ phathead

    You sorely need an education in the reimbursement system for pharmacies in this country. Merely because your copay is higher does not mean the pharmacy ‘pockets’ the difference in copay. Generally, we are make the same amount if your copay is $10 or if it’s $50. Many of the times these changes are due to quirks within the insurer itself. Sometimes they’ll suddenly triple, or more, a copay simply because this month they prefer x drug instead.

    We don’t ‘charge’ you $5.10. Your insurance sets that price. Often times a drug of that nature, plus dispensing fee, will cost maybe $12 total. Between your copay and what the insurance pays us, you know what we typically receive? About $12.50.

    I outlined what the economics of retail pharmacy is like a few months back, perhaps it may shed some light on the situation for you.

    http://www.iwanttobeapharmacist.com/2010/01/economics-of-pharmacy.html

    And the $4 generic prescription programs, while they look good on paper, are a hurting pharmacies more than you know. The average cost of a prescription, before figuring the cost of the medication, is roughly $10. That includes salary, supplies and all overhead costs. When Walmart or whoever dispenses something at $4, they do so at an overall loss, at least, of $6 per prescription.

    How would you feel if you services were reimbursed for under your total cost?

    Yes some pharmacies are more poorly run than others. Yes, there are many techs who don’t know a spatula from a Lipitor tablet. But you cannot generalize these facts as a basis for bashing the whole profession. How many nurses have dictated the wrong directions to us? Just the other day someone wrote a prescription for Avelox 40mg/0.4mL. Because that particular M.D. did that, do I think that all M.D.’s are incompetent? Of course not, it’s a small subset of a very respectable profession.

    Make sure you understand your facts before you go spouting off against something you don’t fully understand. I wouldn’t do that for your profession, so I would hope you wouldn’t do it for mine.

    • http://warmsocks.wordpress.com/ WarmSocks

      What you are saying is different from what my insurer and my pharmacy have told me.

      My insurance company says that my copay is $10/25/40. Everything should cost at least $10. I have been curious about the savings that I get. When I pay only $3 or $5, those savings add up. I’m thrilled to save the money, but wonder why pharmablogs complain about the low reimbursement they see when they are entitled to more money. My insurer claims that the pharmacy chooses to charge less because those particular meds are very inexpensive to fill. The pharmacy also says that they could charge $10, but don’t because those particular meds are so inexpensive, they’re still making a profit.

      If, as both my insurer and my pharmacy claim, the pharmacy is making a profit when they charge $5.10 for piroxicam, then there is no reason to turn around and charge some people $45 for the exact same thing. That is what is happening.

      When the two parties who should know what’s going on tell me the same things, I assume that they are explaining the way things work. Now you come in and say that they are both lying. Or do I misunderstand what you’re saying?

      • http://www.theangrypharmacist.com TheAngryPharmacist

        Here is where the confusion is:
        Your insurer only knows the ingredient cost. Meaning the base cost of the drug. Sure, the drug could cost $3.75 (therefore $10 would make a profit) HOWEVER thats if the labor, vial, sticker, computers, electricity were all FREE. The insurance company has NO idea what the fixed costs are with filling a prescription nor what the overhead cost. All they know is the cost of the drug. Sure, you can make a profit on the raw materials, but lose that profit and more on the labor.

        It costs the pharmacy between 7 to 12 bucks to fill a prescription JUST IN LABOR AND NON-DRUG MATERIALS. Add on a few insurance rejects or billing multiple insurances and the price skyrockets. No pharmacy makes a profit when they charge a total of $10 on an Rx (especially if your insurance company reimburses $0). Hell, you made enough profit to maybe pay for your clerks to take your phone call, and your tech, and the claim transmission costs, and the computer software fees (for the day) with $40. You throw a pharmacist trying to figure out how to secondary insurances and that $40 can be lost in a hot second.

        Why do you think pharmacies are trying to fill prescriptions as fast as they can? Why do you think the most profitable (and slowest) pharmacies are compounding shops that charge a leg for their goods?

        Heres another protip. (To me) there is a difference between a “Standalone Pharmacy” vs a “convenience pharmacy” located in a building that sole’s purpose is not-pharmacy. Take that for what its worth.

        • http://warmsocks.wordpress.com/ WarmSocks

          Makes sense. Bad system. Thanks for the explanation.

      • http://www.iwanttobeapharmacist.com/ phathead

        First, many pharmacists are unaware of what the actual overhead costs of their particular pharmacy is. Often they’ll see whatever amount over cost and think that is pure profit when it is not.

        Second, pharmacies cannot legally change copays, at least in any state I have worked in. How it was described to me is that the copay is, in effect, a contract between the patient and the insurance and we are not to alter it. The legality of this varies naturally, but that is the rule of thumb. Many insurers set those copays as the max you will pay for that particular class. Generally you personally cover the cost of the drug up to $10, for instance, and you keep paying that $10 while the insurance picks up the remainder. If it’s less than $10, than you pay whatever that amount is. This is, of course, grossly simplified, but it’s a fairly simple point.

        In your case, as I’ll get into in a second, I do not think this is the case. Sometimes you’ll have to ask several people before you get a clear answer on the price aspect, that’s the nature of insurance today.

        Now let’s look at your so-called ‘gouging’ of patients on the price of piroxicam. Looking at my wholesalers website, 1 capsule of piroxicam 10mg COSTS $0.90. Meaning for a 30 day supply, at one a day, the cost is $27 for the drug itself. Add on the $10 dispensing cost, and total cost is $37.

        Now you they’re charging cash customers $45, which leaves a profit of $8, a little more than 20%. You also have to consider that those costs will very and that some margins have to be higher because we routinely lose money on dispensing some drugs.

        So in reality, you’re paying $5 for something that costs close to $40. Piroxicam 20mg can be found for much cheaper, IF you can get it in stock.

        I’m not saying both parties are lying, but both are misinformed. I have worked with nearly 50 pharmacists over the years now and only a handful truly grasp the costs behind daily dispensing. And when you’re talking with a rep from a PBM… well ask anyone who deals with them on a regular basis and they’ll tell you how helpful they are.

        Remember that it is the PBMs who are routinely out to make money, not pharmacies. We have virtually no control over what we are paid and what you are charged. It is one of the larger problems within the profession at the moment.

        • http://warmsocks.wordpress.com/ WarmSocks

          Thank you for the explanation.

  • Jen

    If you don’t like the service you are getting go to another pharmacy. I’m sure the staff at your current pharmacy wouldn’t mind. I have 10 years experience in pharmacy and we have never once intentionally over charged a customer. The wavied copayment on enbrel I’m sure was a claim that had to be billed both to your primary insurance and to a coupon I see all day everyday. You work in a pharmacy filling 500+ scripts a day and try to remember who has a coupon for what drug!

    • http://warmsocks.wordpress.com/ WarmSocks

      The cool thing with computerized systems is that you don’t have to remember anything other than to look at the computer. The information is all right there.

      I did eventually change pharmacies so that I wouldn’t have to drive so far. My new pharmacy has not made any mistakes. Ever. Refills take only one day, not 4-5. They always remember to use the Enbrel card. I will never go back to the other place, because the service at the new place is much superior.

      • http://www.theangrypharmacist.com TheAngryPharmacist

        Unless you’ve worked for the pharmacy chain which you are going to, you are making a huge assumption on their computer systems and “its all right there”

        99% of patients have 1 insurance company, thereby anyone with secondary/discount/freebie cards, their Rx’s need to go through a special PITA transaction. Most dont even note that the patient /has/ a secondary insurance. Can they fix this problem? No, because its used so infrequently its not worth it.

        Screen real-estate is a premium on computer systems, There is only so much space to display the primary insurance reimbursement/interactions/doctors information/sig/quanity/tablet-shape/etc. Seconary insurances is used so little that it takes a back-seat to everything else that a pharmacist uses 99.99% of the time. Unless you ask assume that its going to be overlooked.

        Whoever filled your Rx was probably trying to juggle 10 different things at once (as well as trying to have a conversation with a patient about where the toliet paper was while on hold with an insurance company while checking off an Rx).

      • http://www.iwanttobeapharmacist.com/ Phathead

        The length of time it takes to get a refill authorization is nearly totally dependent on the doctor’s office, not the pharmacy.

        City I was just in had a minimum of 72 hour wait before receiving an authorization.

  • jason

    it bugs me to no end to hear people moan and groan about their pharmacies. i stopped working for chains because of how bad the working conditions are, but one of the main reasons they are so bad is because pharmacists in chains are expected to be baby sitters…to their techs and their patients. chains wont pay enough to hire decent techs and patients get spoiled because greedy chains want to have a ‘the customer is always right’ policy. well the fact is theyre not.
    any reasonably competent person who takes any initiative in their own healthcare, who pays attention to their what theyre doing should never have problems. for starters, know what youre taking and why. know how many refills you have on your meds. take the time to go over your formulary with your doctor before he writes you prescriptions. a pharmacy should never have to call to refill your prescriptions for you. i wish they would make this illegal. it should be.
    working for independent pharmacies is not much better. unless you specialize, you can barely break even in the pharmacy. we dont work for free. insurance companies reimbursements are chicken feed. we make a little off cash customers, but they are too few. the only profit we make is off our front ends. meanwhile insurance companies and drug companies are making a killing.

    • http://warmsocks.wordpress.com/ WarmSocks

      a pharmacy should never have to call to refill your prescriptions for you.
      I agree, but my doctor does not. Some of my meds are written for 6 or 12 months, but she won’t write refills for mtx because she wants to see lab results before allowing a refill. I’d prefer to have the refills available and have less work for the doctor and pharmacy staff; I’d know that if my labs indicate a problem then I should discontinue the med until the doctor gives the okay again. The doctor doesn’t see it that way.

      A computerized system should allow the pharmacy’s end to be automated. If a refill is called in, but there are no refills available, then computer could send a fax to the doctor’s office without involving pharmacy staff until the return fax showing authorization arrives. At that point it’s no more work than if I walk in with a paper script.

      any reasonably competent person who takes any initiative in their own healthcare, who pays attention to their what theyre doing should never have problems
      Real life is not like a fairy tale. I’ve been given the wrong dose before (pharmacy error), I’ve been told that my insurance card didn’t work (another tech was able to make it work just fine), I’ve arrived to pick up my prescriptions and discovered that the intern shoved all my written scripts into a paper bag instead of entering them into the computer and filling them. People who work in pharmacies are still people. They can and do make mistakes. My paying attention doesn’t prevent other people from making mistakes and causing problems. The biggest problem I see is that pharmacy workers assume that they are perfect but patients are stupid.

      • Krys Vee

        The biggest problem I see is that pharmacy workers assume that they are perfect but patients are stupid.

        *cough* *cough* *cough* IF one were truly perfect, they would not be assuming it, one would know it. Such knowledge is natural to a perfect being.

        Suggesting that the entire population of the Pharmacy profession suffers from something that can quite neatly be summarized as Narcissistic Personality Disorder is a pretty big diagnosis over *CLERICAL* errors.

        Okay, so an MD’s office has a sheet of paper that they know they faxed-they put it though the fax machine, they’ve stamped it “faxed” and written in the time and date. They then file it in the patient’s records. If an MD’s office is particularly thorough, they might even have the fax confirmation sheet filed in the patient’s records as well.

        In my experience, I’ve learned to treat the fax confirmations as proof that I’ve sent a fax–they really only mean that the fax transmitted properly–that those earsplitting noises from one fax machine to the other did indeed transmit from point A to point B without interruption (the hardware shook hands and data was transmitted. Still with me?). This doesn’t mean that the fax machine at the other end wasn’t: out of paper and had no memory; out of toner and printed something blank or unreadable; or had a paper jam and my unfortunate fax was rendered illegible. Then there is also my personal favorite: when whomever sends the fax errantly feeds it into the fax machine upside down, so what is actually transmitted is a blank page. I know enough to read the headers and see if we can figure out where it came from and call that office; not everyone knows to do this or not everyone programs their practice name into the fax machine so it appears in the headers. That confirmation is nothing more than proof of an act of good faith. So, in good faith your MD’s office faxed that refill request. (I mean this in the Legal sense, not in a patronizing way.)

        And yes, there are atypical occurrences when papers do get sorted wrong and something important mistakenly makes it into the trash, or more commonly, misfiled to be found a few hours AFTER it would have been helpful to have it in hand. Errare humanum est et confiteri errorem prudentis. Right? Right. Not what the customer wants to hear that, but, it’s reality (something I solely broker in).

        Some of my meds are written for 6 or 12 months, but she won’t write refills for mtx because she wants to see lab results before allowing a refill . . . I’d know that if my labs indicate a problem then I should discontinue the med until the doctor gives the okay again. The doctor doesn’t see it that way.

        Clearly, the Pharmacy workers are not the only professionals who question the intelligence of one’s patrons.

        The REAL problem as I see it is that, on average, people residing in the United States are not versed enough in US contract law as well as fundamental principles of economics to truly understand what goes on between employers, insurers, and pharmacies. (The same can be said for what goes on between employers, insurers, and medical providers as well.) Akin to every other for-profit profession out there (and most non-profit ones as well) if the cost outweighs the risk/associated costs of the risk, it doesn’t get done. In pharmacy this is evident in places where communication gaps occur: computer systems that do not allow for a method of taking useful notes/storage of extraneous billing info; enough payroll hours to allow for proactive handling of potential customer issues (e.g. following up on refill requests, intricate insurance issues, or, dosage changes from an MD’s office); and most offensively: the lack of training, regulation, and oversight of Pharmacy Techs. Heaven forbid us Pharmacy Techs ever get wages that resemble those of other para-professionals in the health care industry, we will be hearing about it ten times over. Why? This cost will be passed on to you, the customer. And who is at the receiving end of the kvetching when the costs are more than the patient expects? That’s right, 90% of the time, it’s us Pharmacy Techs. [We sometimes let our RPh's fall on that sword, if only to keep them humble and appreciative of us ;-) ]

        My analogy to my most challenging customers: Retail Pharmacy is 1/3rd Medical Profession, 1/3rd Short Order Cook, and 1/3rd Accounting. So please, let me know how well you can balance your checkbook while cooking multiple orders and talking on the phone to someone regarding their hangnail. Some of the time, mistakes will be made. When mistakes happen, it’s of benefit to everyone that they occur with the checkbook, rather than the “food” order or the medical advice. The checkbook errors can be a mighty big inconvenience, but they haven’t been known to kill anyone.

        Look into this all at a deeper level, and if so inclined, find a way to be part of the solution.

        All the Best,
        Krys Vee, Lead CPhT and pill-counting minion extraordinaire ;-D

  • Candy

    Ahh yes, the evil W. For every story you have about them I have 1 about the ignorant C, bitchy U, incompetent N, and, those liars over at T. If your gripe is seriously just about your refills inexplicably not being ready in time or not being authorized by your doctor or your coupon wasn’t billed than that pharmacy was probably happy to get rid of your dumb ass. Come back to gripe when they fill your Rx with the wrong drug. If you had any clue how often the pharmacy saved your ass from your own doctors errors without throwing them under the bus then you would have more realistic standards for said pharmacy. These people at the evil W may not be the fastest but they are on your healthcare team. So as long as they haven’t poisoned you, them give ‘em a break, be patient, plan better, and maybe say thanks every once in a while.

    • http://warmsocks.wordpress.com/ WarmSocks

      When you swear and call people names, it doesn’t come across as teamwork. My healthcare team is polite and respectful to me, as I am to them. They are thanked, given cookies, and allowed time to do their job.

      Your reply sounds extremely bitter, and as if you made assumptions based on past experiences instead of reading what the post actually says.

  • Serena

    I’ve been a rx tech going on 8 years and I can’t tell you how many techs we’ve had and gone in those years. Most quit before they’re completely trained leaving us to start all over again. The pay sucks for what we have to deal with on a daily basis. The work environment is stressful and were short staffed. Hire more people? No, corporate office says were at ourmax hours were allotted. Don’t even get me started on coupons. The computer system isn’t set up properly to bill these since we have your primary on file unless we know up front to bill the coupon card or it is the only other third party set up its not going to work. Some people bring coupon cards for everything which is fine until the refill. Once these cards are added they are numbers and letters. So its impossible to know which goes with your epiduo and which is for solodyn.

    • http://warmsocks.wordpress.com/ WarmSocks

      Until a better software program is installed to track the information that needs to be tracked, this sounds like something that patients need to be made aware of. I’m quite willing to add an extra little note when I refill things if it makes it easier for the pharmacy staff. Would you be allowed to post a sign stating, “Please remind us about discount cards/coupons when you order your refills.”

      • http://www.theangrypharmacist.com TheAngryPharmacist

        That should go next to the sign that says “please call in your refills 4 days in advance” which is promply ignored by the person standing in line in front of you yelling at us that they are out on a friday night.

        Your discount cards are your responsiblity, thats plain and simple. You should remind the pharmacy each an every time about anything special/tweaky, ESPECIALLY if it only involves 1 Rx in a list.

        • http://warmsocks.wordpress.com/ WarmSocks

          The person who enters all the information into the computer the first time could say something like, “It’s easy for the discount card to be overlooked. Be sure to remind us when you call for your refills.” I was told something more along the lines of, “We have everything we need in the computer now; you don’t need to show the card every time.”

          If the pharmacy needs a reminder, I’m happy to give a reminder. If the pharmacy needs four day’s lead time, I’m happy to give all the time that’s needed. I’d just rather know what the system is supposed to be so I can work with it. Just tell me what makes it easiest & most efficient for me to get my prescriptions given the limits of my insurance policy. These meds keep me ambulatory, so if it means that I need to serve a catered lunch to the entire pharmacy staff once a month, I’ll happily do it. Just make the requirements clear.

          • Krys Vee

            The reality to this? Now, you know. And, moreover, you’ve been taught nearly the same way most of the Pharmacy Techs learn this. By experience, without warning, and usually, under duress.

            Again, it’s not profitable to spend time training techs on the finer points of pharmacy billing. Techs are only profitable when they’re productive. We’re in the last apprenticed “medical profession”, and by that I mean learning strictly through observation and experience. Not that we really learn that much medical information . . .

  • JoshH

    The fact of the matter is that if you want a refill, you should be responsible for calling your doctor. Having someone else be the middle man is just stupid and is asking for problems. The pharmacy has saved me NUMEROUS times by calling my insurance company and trying to get things to go through for me. And, when my doctor writes for things that no insurance company covers or that haven’t been around for 40 years, my pharmacist takes the time to call him and make a recommendation (which usually take another day and a half for the doctor to approve). I know how busy they are and how overworked and I’ve seen how other customers treat them sometimes. So, I’m very appreciative of all that my pharmacy does for me.

    • http://warmsocks.wordpress.com/ WarmSocks

      The fact of the matter is that if you want a refill, you should be responsible for calling your doctor

      If that is your doctor’s policy and it works for you, fine. That’s not how my doctors operate. One of my doctors doesn’t do phone refills at all. I go for an office visit and get a new written script when I need refills. I have no problem with this system. Another of my doctors won’t write for more than one refill and requires labwork before extra refills will be given. When I’ve called to ask about refills in the past (hoping to make things easier for the pharmacy), the doctor’s staff says, “Have your pharmacy send us a fax.” There isn’t a one-size-fits-all solution. I appreciate what my pharmacy does, too. I just appreciate it more when they get things right :)

      • Pharmer Joshua

        “One of my doctors doesn’t do phone refills at all.”

        They don’t because it takes time and they don’t get reimbursed for it. Kind of like how pharmacists don’t get reimbursed for their services, either. You do realize that you can change doctor’s, right? You do realize that you don’t have to see the doctor every single time you need a prescription, right? You do realize that they make more money off of you every single time you come in, right? You do realize they protect their profession through monopoly licensing which artificially raises your healthcare costs, right? You do realize the ultimate source of all of this is the absolutely awful Medicare debacle, right? I sure hope so.

        • http://warmsocks.wordpress.com/ WarmSocks

          My understanding of the system:
          see patients = get paid
          handle things over the phone = work for free

          I believe that people should be paid for their work, and don’t have a problem seeing my doctor every six months so that he can check everything that needs to be checked to be sure that it’s safe to refill my prescription. Sometimes he tweaks the dosage, so I know it’s not “just a routine refill.”

          Yes, I know my doctor earns money every time I have an appointment; that’s why I go in to see him instead of phoning and begging for “free” refills. I read my EOBs and have seen some of the legitimate charges that the insurance company has denied. In addition to the “discount” that the insurer knocks off the charge for every office visit, they don’t always pay what they ought to pay. Within one four-month time frame, my doctor had to write-off $300 that the insurance company should have paid for my care. I learned later that he knew they wouldn’t pay the entire bill, but he took care me anyway (unlike a different doctor who specifically said that he’d only do half the job because the insurance company would only pay for half at a time). I feel like he’s been cheated, and is owed some extra money. So I go see my doctor for med refills and I’m getting to know him better, and he’s getting to know me better. I think that’s a good thing. If it costs the insurance company extra money – well, they brought it on themselves.

    • http://www.iwanttobeapharmacist.com/ Phathead

      Patient’s do not call the doctor for refills, the pharmacy does. That is standard practice nearly across the board.

      • http://persnicketyrph.blogspot.com Jonathan Lloyd

        True. This is the way it is done everywhere. Another thing done widely? Doctor’s offices that tell the patient, while they are leaving the doctor, to go right to the pharmacy because they are calling the prescription in now.
        How far away is the pharmacy? Maybe five minutes. Patient gets to the pharmacy and starts jumping up and down, swearing. “Why isn’t this ready??? It was called in as I was leaving!”
        I’d like to know how those secretaries and nurses know how busy we are? Are they tapping into our security cams????

        • Mike

          Jonathan, that annoys me to no end as well. “They called it in!” “Yeah, but the Dr. is right across the street and, you know, it takes a minute, even though all we are is doing is putting pills from the bigger bottle into the littler one.”

          (This is Mike, formerly of The Pharmacy in Benn., BTW. Hope all is well.)

  • Pharmacy Intern

    At the busy retail pharmacy I work at, we have several patients who are on Enbrel or Humira. One patient has a $400+ co-pay on her Humira; however, she has a card that brings that cost down to $5.

    Whenever there is a “coupon” that needs to be attached to a certain prescription, the process for submitting the claim is different than that of a single third party. For my pharmacy, the claim is first submitted to the primary payer. Next, the claim comes back in an error message because a special “secondary payer” code must be attached to the claim. Then, it is sent to the secondary payer (and hopefully doesn’t give some stupid rejection like “bad birth date”). We generally try to keep notes in patients’ profiles to bill both insurance and coupons.

    What you experienced at the pharmacy is a simple insurance-related mistake that happens numerous times throughout the day. When the husband went to pick up the medications, he should have been informed of the approximate cost. That way, when the clerk announced to him it was $45 for the Enbrel, he could inquire as to why it’s so expensive. Within a few seconds, the secondary claim could have been submitted and he could have been on his way having only paid $5 for a $1500 drug.

    Even if this was not caught at the point-of-sale, any pharmacy should be more than willing to resubmit the claim on your behalf, and offer you a refund (at least we do at my store).

    As for the pricing of piroxicam, I’m pretty sure pharmacies aren’t allowed to charge one patient one amount because they have insurance, then gouge the prices for cash paying customers. All drugs have a set cash price for all customers. (Sure, insurance contracts have been negotiated for some plans.) It is against the law to charge one price for, say, a Medicare patient, then to charge perhaps a lower price for a cash patient.

  • Rxcounter

    In a perfect world, everyone would be cash-paying and hack it with their insurance later. Pharmacies would be able to cover costs and make a decent profit in a reasonable amount of time and patients would have some concept of what they’ve been getting for so relatively little. I tell patients all the time, just because it’s generic doesn’t mean it’s cheap.

    I took the liberty of looking up your regimen on drugstore.com. They’re a bit more pricey than the chain I work for, but it’s within a few dollars for most things and it’s a reasonable estimate. They appear to have a minimum dispensing fee of $14.99, again a few dollars more than my chain and as an online pharmacy they probably have less overhead, but I think it’s safe to assume they’re not actively trying to rip anyone off.

    folic acid 1mg #30 – $14.99
    hydroxychloroquine 200mg #60 – $35.99
    methotrexate 2.5mg #30 – $31.99
    piroxicam 20mg #30 – $76.43
    verapamil 240mg caps #30 – $27.43
    Enbrel SureClik 1 box – $1813.79

    Comes to a nice round $2000 a month. Your pharmacy invests this amount in you ALONE every month and may get repaid within two weeks to a month depending on insurance. Jonathan is right on the mark with the estimate of filling an empty vial – our cost runs just under $9 per rx now. Insurance companies generally reimburse AWP – 25-30% + $1.50-2 dispensing fee. AWP is the average wholesale price – this is what we pay to get the drug, not even as much as your cash price. This adds up to a couple dollars profit per rx – volume is the only way to turn a profit, and that is a whole new can of worms.

    Coupons will generally pay about $2-2.50 dispensing fee, but a significant minority pay nothing at all for your time and trouble. I try to be conscientious and put notes in pt profiles for coupons and which numbers correspond to which coupon, but having been both a tech and a pharmacist, it’s not readily apparent to the techs that there is one, and the pharmacist often doesn’t have the time to bill a coupon. All this is assuming the coupon is already on file – I can’t tell you how many patients wait till after they’ve been rung up to inform me they have one, or even come back after they’ve already left, or most maddeningly of all, never activated the damn thing.

    It sounds like you have the makings of a stellar patient – you call things in ahead of time, you know what you’re taking and why and take the time to make sure you’re getting the right things – but your attitude is still a hurdle. The only prices a pharmacy sets are the cash prices – your copays are your copays no matter where you go. Pharmacies have no wiggle room on this. If you’re not getting good service, feel free to change – nothing is holding you back, and I’m sure it would be a better and happier situation for all involved.

    By the way, the reason some chains can offer $4 lists is because they never bill your insurance – in essence, you become a cash-paying patient, otherwise your cost would be the same as ever. I refer people to those pharmacies all the time – it’s not my company taking the loss, and I’d rather the patient get what they need at a price they can afford (especially if they’re without insurance) than make a measly AWP – 30% +$1.50 and bankrupt the patient.

    • http://warmsocks.wordpress.com/ WarmSocks

      The only prices a pharmacy sets are the cash prices – your copays are your copays no matter where you go. Pharmacies have no wiggle room on this.
      I’m guessing, then, that the contracted price varies from one pharmacy to the next; it’s not a blanket price that the insurer pays to everyone? Same prescriptions, old vs new pharmacy, $3.20 vs $2.45; $5.10 vs $10; $9.20 vs $9.05.

      AWP – 25-30% + $1.50-2 is that an equation with a subtraction sign? Insurance companies reimburse you for only 70-75% the average cost of the medicine, then tack on a pitiful $1-2 for all your work so that you lose money every time you fill a prescription for someone who has insurance? That is appalling!

      • http://www.iwanttobeapharmacist.com/ phathead

        What pharmacies can do on copays varies greatly on the state and the plan, so without knowing either, it’s hard to determine what precisely is at work.

        That formula is correct, but slightly misleading.

        AWP is the Average Wholesale Price which is the effective price for sale of the drug. Kind of like when you see on packaging a ‘Recommended Price’. The usual markup, note usual, is around 33%. So AWP is 33% above acquisition cost (ACQ).

        Yes, some plans reimburse by subtracting 25-30% of AWP (leaving you typically with a range of 3-8% margin) and only pay you a $1.50 of that $10 overhead cost that I mentioned in an earlier post.

        It can actually be much, much worse than that. Some plans give you a mere $0.50 for a dispensing fee. Even more have instituted this new rule where they will only pay for one dispensing fee every 30 days. So if you’re filling your prescriptions on day 29 of 30 each month, the pharmacy is losing out on that income each time you fill it. It’s nothing you’re doing, just a fact of how they try to screw us out of earning our keep.

        Even more will reimburse solely at ACQ for certain drugs they don’t really want to pay for. One of the local government plans in a city I lived in routinely did this so were forced to switch them to something else, even though therapeutically it may have been slightly detrimental to it.

        If you’re truly interested in learning more about this, I have numerous ppt slides from a class I’m in right now that could explain things more.

  • scott

    I think anyone that complains about pharmacy dosen’t understand how a pharmacy works. Pharmacists are educated healthcare professionals. We are not glorified cashiers who need patients to tell us how to do our jobs. Do you really think we want to work in the conditions we have to? Do you think we want to work 12 hours without a lunch break and with a staff that has a high school diploma if that? the public dosen’t see how that the quantity and quality of our help is decreasing everyday. that the coporations are killing our profession so that you can get your prescription in “15 minutes or less”. yes pharmacy has become a circus on display, but its not because its what we want….its what you want. you want the cheapest price and you want it done now. that cheapest price can cost a whole lot which cant be quantified. so maybe instead of complaining about the pharmacy you should take a look back and see that its not the pharmacists fault but the systems fault. dont forget to come into my store and get your flu shot on demand while i check 400 prescriptions in a day. oh and you can wait for all 6 of your scripts. after all we just count them and stick a label on it. our jobs would be so much easier if the public did their part and participated in their healthcare.

    angry pharmacist…love your columns

    • http://warmsocks.wordpress.com/ WarmSocks

      Scott, I got a flu shot in a pharmacy a few years ago. Never again. I’d rather see my doctor and let the pharmacist stick to filling prescriptions.

      As for waiting for my prescriptions, I phone my refills in at least a day before I want to pick them up. I’d rather do my waiting at home and give the pharmacy all the time they need. New prescriptions I drop off and ask if I can return in a few hours (unless I’m sick). If I’m sick enough to have been to the doctor and been given prescriptions, then I plop down in one of the chairs beside the pharmacy and wait until they’re filled. In that case, as soon as that medication is ready, I’ll be going home and going to bed. I really don’t care if it takes 15 minutes or an hour, as long as I don’t have to expend the energy to wander around the store.

      You’re right. The public doesn’t understand the system. So tell people. Blogs are great for that. If you’re respectful, it’s amazing how many people can be reasonable.

    • HJ

      “the public dosen’t see how that the quantity and quality of our help is decreasing everyday. that the coporations are killing our profession so that you can get your prescription in “15 minutes or less”. yes pharmacy has become a circus on display, but its not because its what we want….its what you want. you want the cheapest price and you want it done now. ”

      I thought we wanted a free market health care system that would provide cheaper prices and better service. Why complain…isn’t it better than socialism?

      • Mike

        Warmsocks–

        Question: not trying to be confrontational, just trying to understand. Why do you not like getting a flu shot from your pharmacist? I mean, at the Doc’s office you may get the shot from an RN, LPN, CNA, MA, etc. (at least in my state). Don’t you feel pharmacists are as capable as/more capable than the others? Just curious. Thanks!

        • http://warmsocks.wordpress.com/ WarmSocks

          Cost is a factor, but not the only one. My insurance covers 100% of the cost of a flu shot at my doctor’s office, but it’s $180 for flu shots at the pharmacy for me and my kids.

          Yes, I think pharmacists are capable of learning to give shots. However, last time I went to the pharmacist for a vaccine (placing convenience ahead of cost) I had a very bad reaction. My arm was swollen and red the entire circumference, extending clear below the elbow. It was suggested that I should see my physician for future vaccines.

          • http://www.iwanttobeapharmacist.com/ phathead

            What do you mean by we’re ‘capable’ of learning how to give shots? A bit presumptuous don’t you think? Nursing schools across the country will take damn near anyone nowadays, but some of the brightest people in the medical professions are only ‘capable’ of learning how to give shots?

            And your experience sounds more like a reaction to the vaccine rather than something the pharmacist did.

          • WarmSocks

            @phathead
            Mike asked if I thought pharmacists are capable of giving shots. I said yes, they are. No offense intended. It’s something that ought to be learned; people don’t just one day start jabbing needles into others haphazardly. It’s a learned skill. You think I’m overstepping the bounds of propriety to presume that pharmacists can learn to give shots? Sorry. The pharmacists I’ve known have been exceptionally talented individuals, and I think they can handle it.

  • Angie

    Another issue with cash prices is that a pharmacy may get pirxocam from one manufacturer for $.10 a pill but another manufacturer costs $.90 a pill. And a higher strength may cost less than what you take. The $4 lists say this in VERY SMALL print. These are prices that the corporate office has negotiated with the drug companies. There is NOTHING the tech or pharmacist standing in front of you can do about that. And as for someone telling you all of the little tips and tricks that could help you, they can’t assume anything about you. They would love to be able to tell you these tips but since they are most likely doing all the things that Angry mentioned it’s kind of hard to take the time out from these 5 things that they are doing to stop to tell you to remind them of your coupon. And you are more than welcome to create a new software program that would give the staff everything they need. They would be your best friend if you did that. Do you think they like getting yelled at because the drug company (who by the way is gouging you) decided to take a few tax write offs by sending out these cards? You may not yell at them, but I promise you there are others that are yelling and screaming and making complete idiots of themselves when half the time it’s their fault to begin with. Though I’m not as experienced as some of the other commenters and I have been out of the game for a while, I hope that I have helped you to understand the cash prices and that techs would love to be able to spend 20 minutes with each customer, it’s just not plausible. I’m glad you have found a pharmacy that can and will take care of you.

    • http://warmsocks.wordpress.com/ WarmSocks

      Thank you.
      It has always been my opinion that programmers should spend a little time working in an area to learn first-hand what the software needs to do, rather than making assumptions or imposing an ineffective system on people. Someone who has worked in a number of different pharmacies in a variety of capacities would be most qualified to help define what a program ought to do. I don’t do much programming any more, but might pass this along to a friend who’s still working as a programmer.

  • ThePharmerGuy

    You my friend need a real lesson in how a pharmacy works. The first complaint may sound valid. I have never heard of such a thing unless there was a computer system failure or the pharmacy was so busy that it was that backed up. Either way most pharmacists I know, including myself will rectify this problem as soon as possible. That aside pharmacies do not gouge patients without insurance. The insurances gouge people without insurance. Because so many insurance reimburse damn near nothing for prescriptions (sometimes pharmacies even take a loss on filling prescriptions, now who’s gouging who?) that the cash price must be inflated to assure a proper reimbursement from insurance. Due to some fair practice laws, this means somebody without insurance will pay more because how much the insurance gouges the pharmacy on reimbursement. I could go for days on this but will stop hear to avoid a LONG rant.

  • r watkins

    Isn’t the big message here that even informed, pro-active patients have no idea how the insurance companies and their co-travellers (the PBMs) have completely corrupted the American health care system? Every day, my wonderful staff is vaisciously attacked by patients for problems caused by the insurers.

  • scott

    i think the system in general is in a downward spiral. its not anyone in particulars fault. its a culmutive problem. the corporations set the standard that we need to deliver the service fast and cheap. the majority of the public begin to expect that. corporate america sees that as a positive response and the cycle continues. they only way things will change if pharmacists stop being pansys and start standing up for themselves. i think the public for the most part can be understanding and respectful of our profession. the corporations keep pushing us down. the first step is for pharmacists to say enough and stop allowing the big companys to force us to run like a circus. we dont want to work under these conditions so why do we allow them to make us??

    • Pharmer Joshua

      It may start to change as the part timers get laid off and stop seeing retail pharmacy as a job and look at pharmacy as more of a profession, which it is. People have forgotten this because the chains have diluted the public worth of the pharmacist. Pharmacists don’t need to be in these pharmacies anymore. They need to be at the point of prescribing to help patients save money, headaches, and make the best use of medications. Medication nurses and pharmacy techs can handle the workload at the chain pharmacy drive thru just fine.