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When bad PBM’s get even worse

·4324 words·21 mins

Over the last 200+ entries, I have fought for truth, justice and AWP -5% + $6.50.  I’ve laid down the smack against doctors, other pharmacists, drug-reps, insurance companies, Liberty Medical (fuck you) and even myself.  Now someone else is on the angry chopping block.  This rant is a magical mix of useful information and gutter-talk.  My mother is probably so ashamed right now, however like most of our readers she forgets this is the ANGRY pharmacy and not

Like a pimp who never loved you, these assholes of our profession both give us money, and screw our asses when we’re not looking.  Can’t live with them, cant work with them, but like a case of herpes wont ever be completely gone.

Yes, I’m talking about PBMs.  Pharmacy Benefit Managers.  The people who process your prescriptions and write out your checks every month.  WellPoint, Argus, Medco are all examples of PBM’s.  See on your insurance card at the Bin and PCN (Processor Control Number)? Thats so we can transmit to the correct PBM to get paid for your Vicodin and Soma.

You look confused (surprise surprise), let me use an example.

For those not in the profession (and 99% of the doctors out there), most insurance companies don’t administer their own pharmacy benefits.  Say for example we have a small Medicaid plan called “HealthPlan of AngryLand” (HPAL) that has hired a PBM called PillConcussion (PC) to process the pharmacy benefits.  When your local pharmacy processes that Rx for Soma, our computer systems contact PillConcussions servers (whom have a list of medications that HPAL has deemed “covered”) and right then we get a response if its covered and how much we are making.

PillConsussion pays the pharmacy for the Rx (say, $15).  HPAL pays PillConsussion what they paid the pharmacy ($15) + a handling fee (remember this!, more later).  So the flow of money goes:

State -> HPAL -> PC -> Pharmacy -> TAP -> Webhosting Bill/Booze/Hookers/Blow/Therapy.

Now, the big boys (BlueCross, Medco) process their own Rx’s, so the actual insurance company and the PBM are one in the same.  However smaller insurance companies cannot afford the infrastructure to process their own prescriptions so they hire a PBM (like PillConcussion) to mange their Pharmacy Benefits (hence the term Pharmacy Benefit Manager).  Now, this all may look fair and good, but what if PC goes crooked?

Example 1:
Brand new generic comes out.  Say its Paxil CR.  Now imagine that you have your head up your ass, and you processed the script for the trade name (because the patient has been on it for years) without switching it over to generic (which until this point you had no idea it was out).  Unless you look carefully at your reimbursement screen, the PBM will silently accept the transmission for BRAND NAME and reimburse you the price of the GENERIC (remember, you are transmitting the NDC of the TRADE name product).  No warning from their end, no “BRAND NAME NOT COVERED”, just a normal billing acceptance for about 95% under-cost.  That means that the pharmacy is getting the generic reimbursement ($4.00) when the PBM knows they are billing for the brand name ($200).  Your store just lost a shit-pot full of money because you blew past the reimbursement screen (although most pharmacy systems will blare warning lights at that point).  What makes this whole ass-raping even sweeter is that usually this shit happens when a new generic is released that the PBM’s know about long before you do.  Its pretty sad when the pharmacies find out that a new generic is available by the PBM’s gently patting your behind while softly telling you to lube up and bend over.

Example 2:
Say we take something random and stupid like Prilosec OTC and its generic Omeprazole OTC.  Now what if PillConsussion /only/ covers Prilosec OTC (the brand name), but reimburses the pharmacy the cost based upon Omeprazole OTC (the generic) and at the same time charges HealthPlan of AngryLand the cost of Prilosec OTC?   PC is billing HPAL the cost of the BRAND name, but reimbursing the pharmacy a cost based on the GENERIC.  Is this fraud? Would this be like the pharmacy billing trade name Cipro to the insurance company but dispensing the generic?  Its not as uncommon as you think, however most pharmacies are too busy/stupid to look at how little they are making and not speaking up.

Now in this example say that HPAL and the pharmacy talk and compare notes.  Like a guy who realized the girl he just nailed was 16, PillConcussion starts to do damage control.  They state that generic Omprazole OTC is not covered because the BRAND name is Omeprazole Magnesium and the GENERIC is just Omeprazole and they are not equivalent…

….Must ….Resist ….PBM ….Backward …Logic

Still doesn’t explain why they will not cover the generic but reimburse based upon the cost of the generic.. They then say that it was a computer error, and to BACK OUT AND RESUBMIT ALL CLAIMS FOR THE PAST X MONTHS.  Now here is what really confuses me.

If PillConcussion audited you, and realized that you were overcharging for a certain drug, would they have you BACK OUT and RESUBMIT all of the incorrectly billed claims? FUCK NO! They would just take ($difference x claims) out of your next check.  Now why can’t they do that with the errors that THEY made?  They know how much the price was off in the computer, and they know how many claims were processed, so why cant they just issue refunds to the Pharmacy (whom they were under-reimbursing) and to HPAL (whom they were overbilling).  Its bullshit that they make US do the work for something THEY fucked up on.  “I’m sorry that we fucked you, now get fucked even more with the $0.20/transmission charge you will get to BACK OUT and RESUBMIT to get an additional $0.50/rx”

Yeah, hear that sloshing noise, that’s coming from your backside.  Someone is getting the good end of this deal, and its not HPAL nor the pharmacy.  The processor is making MORE per Rx than the pharmacy, and all they have to do is just have a handful of servers setup to do processing.  The patients don’t even call them (nor know they exist).

This rant was started by an email I received about a PBM that is plaguing a good friend of mine.  I sent off a few emails to people in the area (I know a metric (not imperial) buttload of pharmacists everywhere, ah, fame) asking them about said PBM, and I received the same gripes/complaints from all of them.  This one however took the proverbial cake.

    I knew I was getting
fucked, but didn’t realize whose dick was in my ass.  All this time, I have
been blaming the insurance companies (who are not innocent by any means),
but it is the PBM that is really putting it to pharmacy and the health
plans.  These cock-smokers lower our MACs on a whim.  Hell, they
are lowering them before the fucking generic hits the
market.  Mean while you would think they would be lowering the
cost on those same meds to the health plan–no fucking way, the PBM pays us less
and doesn’t pass on the savings to the health plans.  Try to get
these same assholes to raise the MAC when
price goes up — good luck Charlie.  If you forget to dot an
i, they point that out without addressing the problem.  The cock-suckers
must be deaf and mute, because they can only communicate by email. 
If you work up the ladder at the PBM you begin to find
older pharmacist who at one time had their own pharmacies.  I have
to think they either couldn’t cut it without daddy’s money or tried to
fuck the public too much.  It is an IMPACT
we cannot afford to ignore.  You owners out there have a
choice–either stand up or lay down like a beaten dog.  Take the time to go
after these assholes now.

Now I’ve been sitting on this post for a long time, because this PBM decides to shoot themselves in the foot time after time (and I don’t want to make 100 posts about how shitty they are).  I just received an email from this same pharmacist saying that this PBM he is talking about (the one that has made an IMPACT on him) is doing an on-site audit at the end of August.  However they just audited him in March and found no significant errors (only stupid shit like a 1oz tube of cream being billed at 29gm instead of 28.95gm).  Now, I realize that sometimes we can be a bit slow, but since when do PBM’s audit you TWICE in 4 months unless you call them out on something huge and they want to get even.  What does a call to the auditor result in? “Oh, we’re sorry, this is a COMPUTER ERROR we will cancel the audit right now.”  Right, a “mistake” and a “computer error”.

So I’m just going to post this now, because I doubt that this PBM can shoot themselves in the foot any worse than they already do.

Comments #

Comment by on 2008-08-13 15:05:10 -0700 #

fuck PBM’s! We got an audit for one unspecified PBM, they couldn’t find anything wrong with the actual prescriptions in terms of day supply or quantity or any “normal” issue.. so they started to go after little nitty gritty things.
*No date on rx
*License # we submitted was off by one letter (even though their system can recognize incorrect/correct licenses)
*Patient’s address wasn’t put down on the rx, therefore making the whole rx invalid
When did fucking pbm’s become the state inspector and started to enforce shit ? just another scam for them to take back money
scum fuckers

Comment by David Stevens on 2008-08-13 16:01:01 -0700 #

How interesting…I have complained to this same PBM about payment times and they made an IMPACT on me by not answering my questions/phone calls and emails and instead sending me an audit notice. I made it through the audit just fine and six months later informed the local insurance plan that uses them of their BS, fucking spread pricing wich was pushing my part D customers into the donut hole quicker. I immediately recieved another audit. These people are just asking for someone to go to San Diego and go postal on them. Oops, may you can figure out which one I am talking about. I can survive their audits but…
NCPA has a video called “Myth Lies & Deception, The Truth behind the high cost of prescription drugs” They are asking people to take a look at it and then buy some at a low price to give to local health plans and the self insured companies that use PBM’s. It’s an eye opener and these bastards are scewing the system more than any of us know. By the way CMS is working on a fix for spread pricing. The PBM’s call it “lock in pricing” I call it crap!

Comment by one_angry_tech on 2008-08-13 20:05:41 -0700 #

I’m just a tech.. but is there a really GOOD reason why all of a sudden state/federal health plans will NOT pay for generic?
Protonix.. covered.
Generic… not covered.
Flonase… covered.
Generic… not covered.
and so on, and so forth.
And why the hell do I keep getting retrys when I try to bill insurance companies? WTF.

Comment by ADHD CPhT on 2008-08-13 20:14:25 -0700 #

“(although most pharmacy systems will blare warning lights at that point). ”
Yeah, like when we have to match that $0 antibiotics bullshit.
Above is about the equivocal message the computer spits out before it has an electronic seizure.
That being said, fuck PBMs.

Comment by Google Account on 2008-08-13 21:11:15 -0700 #

UGGH! I am so tired of dealing with PBM’s I don’t know what to do. After having some phone jockey at random Medicare part D PBM tell me to “calm down” after her company screwed the pooch on my claim, which I vocalized (rather calmly, all my staff thought, anyway) to her, I almost had an aneurysm. If I could have squeezed my cells through the phone I would have ripped her stupid tonsils out of her throat. Then I boosted Teva’s stock by sucking down a half bottle of Sertraline. What do we do? How do we stand up to them. If anyone has any ideas or ways that work, please share!!

Comment by Google Account on 2008-08-14 12:55:40 -0700 #

i just love it when they decide that only a certain drugs are covered. i got yelled at by a pt. ’cause he has to pay full price for his wife’s davorcet-n (it’s not covered under his rx plan). vicodin is covered but she’s allergic to hydrocodone and codeine.
i also have friends who want to work for PBMs ’cause they just loved the managed care part of it.

Comment by Google Account on 2008-08-14 17:34:36 -0700 #

ok, I know you’re an angry pharmacist, and I gather that you hate PBMs. Maybe you could help me with this possibly-related question…
I am a health-care provider who does not have prescription-writing privileges. I am also fairly new to my profession, and am trying to follow all rules, including ones I may not know about.
Recently I received a phone call from a PBM telling me that a local Big Corporate pharmacy had submitted claims for 2 prescriptions (for muscle-relaxants) using my NPI number. I’d never heard of the pharmacy and I’m sure they’d never heard of me. Since am a health-care provider who does not have prescription-writing privileges.
Since I am trying to be a good little rule-abiding new health-care provider, I asked the PBM person what I should do, and she suggested I call the pharmacy and ask them to reject anything with my NPI number, since it was bound to be fraudulent.
I called the pharmacy, finally got connected to a pharmacy tech who said he didn’t know what in the world I was talking about but would dutifully write it all down for the pharmacist.
After about an hour, the pharmacist called me back, asked what in the world I was talking about, and hung up on me two sentences into my explanation. I called the number back and got the fax machine, so I figure he really, really didn’t want to talk to me.
My question: did this piss off the pharmacist because

  1. he was angry
  2. I’m an idiot
  3. the PBM should have handled this
  4. this was not really a problem, even though the PBM made it sound like I might get in trouble
  5. some other reason
    Curious (someone who’s really not an idiot, just new)

Comment by nodrugs4u on 2008-08-15 01:23:03 -0700 #

I wonder how wide spread the problem is. I work for a chain and therefore clueless about this. I’ve noticed some adjudicated less than costs or the profit is $0.15. Calls/faxes to our corporate office came back with stupid responses such as “thank you for bringing this to our attention. The matter has been referred to the appropriate department for further investigation.” What? I’m their employee, not some reporter asking for a comment. Anyway. I wonder if the PBMS owned by chains do this to their own pharmacies.
Quick note on the PBM auditors. Since thy are mostly women, I flirt with them while they work (no matter how much I want to put a bag over their heads), they still pick on dumbass things to justify their existence, but at least they are picking on meds that are dirt cheap. So instead of potentially losing hundreds of dollars, we’re losing just about couple of hundred dollars. What can I say, I pimp myself out to save my company money. This usually happens if you have a boss that you respect and who respects you.

Comment by chilihead on 2008-08-15 10:18:53 -0700 #

I came across this report about PBM’s at the Clark Howard site and thought about this “I hate PBM’s” entry. Patients need to be aware of a new issue regarding PBM’s that could harm them in the long run. Here is the article:
Aug 14, 2008 — 200 million Americans have a health “credit report”
The Washington Post reports that health “credit reports” have been compiled on 200 million Americans. Ingenix and Milliman are 2 companies that make billions of dollars developing profiles based on your prescriptions. A “pharmacy risk score” tells insurers the risk level you pose to them as a potential customer.
Pharmacy benefits managers (PBMs) actually sell your information regarding prescriptions. PBMs are a popular option at companies because they offer cheaper prices when you get your drugs online or through the mail — instead of at a retail pharmacy.
The info in your health “credit report” can be used by an insurer to charge you more or decline you coverage altogether.
Another wrinkle in the story comes with “off-label” prescriptions. Off-label refers to using a prescription for an unintended use. For example, your doctor may be using a depression medication to treat your stomachache. But that off-label usage could redline you with insurers who don’t want to see a history of depression medication — even though you’re not depressed.
Under new federal rules, you are allowed to see your health “credit report” from Ingenix and Milliman.
However, the real problem is not the lack of privacy, but rather the way that insurers are allowed to redline you. We need insurance coverage based on community-rating standards — that is to say, age and sex.

Comment by Steph on 2008-08-15 11:27:54 -0700 #

Class action? Aren’t the chains getting screwed over, too?

Comment by Cathy Lane RPh on 2008-08-15 13:21:57 -0700 #

This sounds like harassment on a grand scale.
I should think they could be called on the carpet for trying to wield ‘police’ powers when they’ve not been designated ‘policemen’ as well as interfering in others’ businesses.
Aren’t the Boards of Pharmacy the authority in a state to determine fitness of a prescription? Is the PBM practicing pharmacy judgments without a license/authority?
I seriously doubt that PBMs are made up of registered pharmacists…since when do we eat our young?

Comment by Google Account on 2008-08-16 15:11:58 -0700 #

In the hospital world we have a similar group of ball breakers called “the joint commission”. Their lameness and audacity is fucking overwhelming. All so the broke-assess of America can get their free dinners at EXACTLY 104 degrees fahrenheit. I’m stupid for being a nurse. I need to find a job where I justify my employment and make myself relevant by changing the same retarded rules every year and get paid stoopid amounts of money for it. Like the American Heart Association. They change CPR every fucking year and act like it’s the gospel of jesus changing the rate of compressions on their dummies.
Beaurocratz rule.
The MBA’s won. We are all just bitches now.

Comment by Done With Retail on 2008-08-18 06:14:34 -0700 #

This makes me sick to my stomach. I mean, I know things were going wrong somewhere, but…damn!
Side Note:
I agree with these audits; they kill me. They do make shit up. Telling me the prescription filled for Jane Doe was filled for the wrong person, when the prescription, in fact, is written for Jane Doe. And when a patient was stranded in another state without his HIV meds. We mailed them to him since he had $0. But since they were not signed for, guess who heard that sloshing sound behind them. Yep. Us. They took every dime back.

Comment by Crusty RPh on 2008-08-18 17:51:35 -0700 #

I have been complaining for months about a certain PBM’s MACs being the lowest in the industry. While on vacation, I have been composing a termination letter. Before I can send it, I get a call from work informing me that they are cutting another dollar from the reimbursement. We fill 400 rxs per week for this PBM, so the first letter was difficult to write. But, it is now very easy to send. I think it is a bluff on their part to get us off their back. They are offering less so when it actually does not change we will feel we have won. Bullshit!! Cut off my head – don’t bleed me slowly. The bastards are still making more per prescription than we are. Crusty RPh

Comment by P.H. Armist on 2008-08-19 06:26:10 -0700 #

I had an awful day yesterday (being a Monday I was beset by 1) People who went to work sick Friday thinking they’d get better over the weekend and infected a dozen others in the process, and 2) addicts who pumped all their Lortab into their veins Saturday night and realized they needed a new Rx when they woke up Monday morning). I just found your site this morning. Absolutely hilarious!
Just make sure you mention the PBMs get money from 1)the employer for administering the plan + money for scanning transmitted Rxs for DURs (what a joke), 2) Patients as part of their monthly insurance premiums, 3) The umbrella medical plan, 4) Kickbacks from the state, 5) Kickbacks from drug companies for putting their drug on the plan, and 6) From pharmacies for every claims transmission…let’s see $0.20 for every Rx times 2 billion Rxs per year…I’m in the wrong business…And people wonder why healthcare costs are through the roof??? We’re supporting a middleman who just sets up computer servers to process claims! As a chain retail pharmacist I may make good money, but at least I’m providing real services for it.

Comment by Vulgar Foul Bastard Pharmacist on 2008-08-19 16:21:07 -0700 #

I can tell you why. Same reason as why the higher ups decide on a certain 10 million dollar absolute piece of shit unusable all-in-one EMR deal that is pure fucking vaporware. Bucks in the pocket, new Corvette in the driveway (well that was a couple years ago to cover shit up), blow, and 16 year old Thai girls appearing out of nowhere. Only for the bigwig that had the power to decide but had never ever even seen the piece of shit they ordered their couple thousand employees to make work. Fuckers.

Comment by KDUBZ on 2008-08-20 06:46:54 -0700 #

In a few words…. FUCK PBM’s

Comment by Crusty RPh on 2008-08-20 14:08:07 -0700 #

There is a 75 minute CD by Dr Mark Riley “Myths,Lies,and Deception” (The truth behind the high cost of prescription drugs)– It is then information the PBMs don’t want you to know. It is a must see for all companies buying prescription insurance. Each and every pharmacist should also watch and make sure the responsible insurance buyers in your school district, city/county government and any large employer in your community should see.
You will see that all the comments above are just the tip of the iceburg. These PBMs are a cancer to medical care. It is like paying the fox to watch the hens. We have found that when the pharmacy gets a reduction in pay ie. MAC reduction, the insurance carrier/health plan gets no benefit from the reduction. It goes directly into the PMB’s pocket. If you complain they send you a new contract for less. The only way to fight is to say no. The chains are fed up also, but they are just starting their own PBMs.
Crusty RPh

Comment by D Stevens on 2008-08-21 16:51:56 -0700 #

two reasons some plans are going with brand instead of generics. Some generics are only 10 or 20 percent lower in price than the brand. Imagine a $10 copay for generic and $50 for brand on Protonix. The insurance plan/PBM would actually pay more for the generic, not less. The other reason is rebates. We get a crapy 2 bucks if we are lucky on a brand as a professional fee. The average rebate that usually goes to the PBM on a brand is 5-6 bucks (OIG accounting office report). Flonase has to be a rebate issue or a special deal with GSK.
System sucks, really sucks.

Comment by TLH,PharmD on 2008-08-23 17:26:24 -0700 #

I work for a chain and I always wonder how they can continue signing these offers. Although one supervisor told me that it doesn’t matter how much money we get as long as they buy a front store item we will make money. Maybe chains are becoming like Wally world and using pharmacy as a loss leader. We as pharmacist need to realize this and save our profession before we become commidities like everything else…..

Comment by cory on 2008-08-24 14:45:47 -0700 #

Just processed a prescription for Protonix generic and the SMF insurance (formerly PAID) said not covered, only the brand name is covered. So what Wyeth and Merck are in cahoots now? Damn and I made a whopping $1.25. ASHHOLES.
p.s. SMF means scumbag motherfuckers, which is what they are all collectively known as by me now

Comment by D. Rugseeker on 2008-09-23 06:40:50 -0700 #

Sorry, apparently I can’t send you an email through the anonymous proxy I’m using, so I’ll just post this here… Feel free to copy it into a seperate post, if you think it’s worth commenting on….
Boy, do I have a story for you, about the evils of computers…
(BTW: I submitted this to another pharm-blog, but the guy thought I was a troll… As if druggies such as myself can’t put a coherent sentence together

Comment by lily acosta on 2009-09-17 12:45:35 -0700 #

Quick question, what’s a reasonable price for transmission or switching charge? Some told me it’s 30 cents(i know that’s high) others range from 0.05-0.15. but what’s the rasonable? thanx