Let’s Learn Some LINGO!!: formulary

One fun word to add to your pharmacy experience repertoire is “formulary.” You may agree this word is not so much fun in a minute… Well, I don’t know… It is a little bit fun.
A formulary describes what medications are or are not covered on your pharmacy plan.
Your insurance company has researched and determined what medications, in their opinion, are the most cost effective choices available. Allow me to say it like this: the cheaper drugs that are still safe enough and useful enough to help you are on this list that is updated every six months or year or so. And they are sometimes “tiered” to offer more choices and price options. Your pharmacy insurance carrier usually uses a PBM- pharmacy benefits manager to 1. Manage the pharmacy benefits (I love being Captain Obvious) and 2. Add another group of people to the alphabet soup of pharmacy benefits.
What the heck am I trying to say? There are so many medications available to choose from for any given disease. In another piece, I wrote about how a prescriber will choose treatment based on knowledge and familiarity. The PBM’s narrow that choice down by choosing from the drug vortex what they have determined to be the best choices based on how well the drug works and how much it costs. The PBM is in place not only to save the insurance carrier money but also you AND hopefully the entire healthcare system.
What the heck does this mean for you? I would STRONGLY suggest you obtain a copy of your formulary and take it with you to your doctors appointments so they can use it as reference when ordering your prescriptions. As far as I know at this time, doctors offices do not call and check if the prescription they ordered is covered. It is a very common occurrence at the pharmacy for the price of your medication to be much higher than you expected because it is on a higher “tier” or not covered at all. Most formularies are available online in PDF format; just see your pharmacy benefits card for website info or customer service phone number. If an online version is not available, a paper one should certainly be.
Thanks for reading me and I’ll see you again soon at the counter. (I’m going to try some catchy pharmacy-savvy closings.) ūüôā

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PRIOR AUTHORIZATION?! WHAT THE?!

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Hi everyone!  I want to give you an explanation of one of the more frustrating events you may face when dealing with your prescription:

OK, so, you’ve been to the doctor’s office and may have waited an uncomfortable amount of time whether you were there for a routine visit or for something that just came about (or has been lingering and you finally decided to go… I do the same thing… shh don’t tell)– not to mention the drive there may have been hectic, you may have had to find a sitter for your children, you may have had to take your children with you, and if you’re human, you have hundreds or thousands of things flying around inside your head. ¬†And after all that, you now have to go to your pharmacy… more than likely. ¬†Or at least you will have to go at some point. ¬†I’m speaking to you.

Your doctor has ordered a prescription for you to treat your condition. ¬†Doctor’s will order what they feel is appropriate, necessary, and is familiar to them. ¬†Most doctor’s offices that I have dealt with do not call your prescription insurance to see if this prescription is covered. ¬†In their defense, they are not staffed to handle such calls which often require ridiculous hold times. ¬†(And as an aside, I have called from the pharmacy to ask what medication WOULD BE covered in a given situation and was told that they were only allowed to give that information to the insured.) ¬†Again, the doctor (I’m using this as a general term here… feel free to insert PA, NP, FNP, CNP, CNMW, or simply your “prescribing provider”) orders a prescription based on familiarity with how well it will treat your particular case taking into consideration your other medications and health conditions.

Now you are at the pharmacy and the lady or gentleman at the counter is telling you that your prescription is not ready because your insurance is requiring a “prior authorization.” ¬†As I type that phrase, I hear sinister music play. ¬†Most responses from our patients have been similar to, “What do you mean it needs authorization? ¬†My doctor wrote a prescription… isn’t that authorization?” ¬†This is a very fair argument. ¬†However, in the world of prescription insurance, this is how it goes: ¬†the doctor ordered a medication that may be much more expensive than a similar medication that would do a similar job. ¬†The phrase “cost-effective” is used to describe this principle of a medication that will do a similar job for less cost. ¬†Expand that over the nation and we should see big health care dollars savings. ¬†I need to leave that to the pharmaco-economics experts.

The next reply we often hear from now-frazzled patients is usually something like, “My doctor thinks this is the best medication for me so how can my insurance try to tell him/her how to treat me?” ¬†Unfortunately, the answer I was given by a pharmacy-benefits-management representative was something along the lines of, “If the patient wants to be a part of our group (i.e. if they want to be insured by us), they are subject to our rules and regulations.” ¬†Part-of-the-group means suffering with the group. ¬†My opinion, though, is that this is a good example of trying to contain health care costs– which again goes way above my head once leaving this level.

So what does this mean for you as a pharmacy patient and customer.  Well, hopefully, one of our staff has called to notify you of the problem unless you came right from your appointment in which we may have not even seen your order yet.  What we do at the pharmacy is to notify your prescriber of the need of prior authorization (another term you may hear is prior approval) for the medication they ordered.  They have the option to submit whatever forms the insurance requires of them, change the medication, or completely cancel the prescription.  I have seen all of the above happen in response to request for prior authorization.

“But I need the medication now!” you might say to us friendly people– well hopefully we’re all friendly. ¬†At this point, though, we cannot do anything until this is resolved. ¬†If this prescription were to be replacing an existing prescription, you may be able to continue on the one you’re taking until this is resolved. ¬†Otherwise, we are required to wait for clarification.

Communication is definitely the key to this situation being as painless as possible. ¬†When we at the pharmacy drop the ball and forget to call you to give you a heads up, we may cause you the inconvenience of a wasted trip. ¬†If you blow up at us and demand your prescription, you don’t make the situation any easier because the pharmacy is not the one holding-up the process, it is the prescription insurance. ¬†So let’s do our best to be educated on situations that may arise that may make all of our blood pressures rise. ¬†As long as we communicate with each other as best we can with mutual respect, we should be able to navigate the waters of your pharmacy coverage a bit smoother.

Thank you so much for reading!  If I can answer any questions your may have, please leave a reply! 

Personal Pain

Chronic pain was a mystery until the experience fell to me. I would often catch myself being judgmental and uppity while behind the bench and filling a prescription for someone in constant pain needing narcotics. Though I myself have not had a narcotic prescription, I can now empathize with folks in chronic pain and how they might feel misunderstood and judged. Even family members can question the validity of the pain.
I write this entry today to say that pain is very real to the person in pain. An outside observer may quip “ain’t nothing wrong with him!” because they cannot see any reason in their mind for pain. I can still be smiling and joking in brief conversations while I’m in disabling pain. I have heard “well if you’re well enough to smile, you’re well enough to work” from my very own family. Pain is difficult to understand until you are the one suffering.
Today, my entire body pulses with pain. Literally non-stop pain is stomping around my nervous system causing me to have trouble walking, concentrating, typing, writing, standing, sitting, or playing with my children. I would never have believed anyone saying their pain never slept. This concept of around-the-clock with no-letting-up pain is daunting. I don’t like it. I don’t want it. But now I understand it.
My body will have fits of waves of pain and an insane cascade of restless legs and an insatiable desire to stretch and contort myself to find relief. I have pictures of me bent backwards on the edge if my bed with my legs impossibly stretched and arms reaching and neck bent all the way back and to the right. My wife laughed and said I should have been a dancer. But all joking aside, she struggles with this concept of “my husband looks fine but acts completely tortured.” This certainly does feel like torture or some ridiculously slow poisoning.
Wrapping this up… Pain is pain for the person in pain and pain can be a pain for the person close to the person in pain. Be compassionate toward people in obvious chronic pain though you may not see any outward reason. There are so many etiologies of pain that seem invisible until you point an MRI at some body parts, study the blood chemistry, or observe the effects on quality if life.
Live and love with peace and shower each other in excellence and admiration.

Appropriate Question Appropriate Time

Did you ever wander a store with increasing frustration aiming for shopping list targets and missing the mark? And when you ventured enough courage… And humility… You politely ask an employee where you might find something-or-other.
Now the response from the employee will depend on several factors: 1) employee’s experience 2) employee’s mood 3) employee’s area of expertise or lack thereof 4) how you approach with your question. (A little bit of kindness and a genuine smile go a long way with someone who is having a bad day.)
There will be times you interact with a brand new employee. Why would they put someone with no experience in a store you frequent? The answer is simple: to get experience. They can’t gain real life experience without having real life experience; and I realize this doesn’t help when you are in a rush or have already had a terrible day. Also, the employees “newness” is a relative term. Experience in store operations is only gained… you guessed it… based on how much time the employee actually spends on store operations. So you can imagine someone working twelve hours a week would be less able to help you than someone who works forty hours a week (or more!!!) Unfortunately, you won’t know the level of competence until you ask your question and gauge the reply. New employees are trained that if they don’t know the answer to a customer’s question, they find someone who does.
The next consideration is our humanity. We ALL suffer with foul moods whether we want to admit that or not. Some of us are far better at handling our moods than others. However, when you as a customer enter a pharmacy I am sure you don’t expect to be met with an employee’s personal baggage. But this does happen. Personal life can and does spill over into the work life as much as we try to prevent that. At the very least, the emotional affects take a toll on professional affect. Too many times I have seen an employee fly off the handle at something they usually handle well like a patient’s reaction to a prior authorization for example. The result of which depends on the amount of mercy and grace the patient has stored up. I still have echoes resounding within my mind of explosive interchanges between employee and patient. Not at all where any of us wants to be.
Moving on to area of expertise, I want you to consider that the employee you approach may not work in the area your question envelopes. For instance, asking a pharmacy department employee where to find dish soap and panty hose may result in a look– yes, you know the look– depending on the level of friendliness and how much patience is left. Likewise, asking front store personnel which medication would be appropriate for your child’s constipation would be inappropriate regardless of their enthusiasm for answering. My point here is for you to not be shy about asking first, “Are you licensed to answer questions about medication?” or “Would you know where to find dish soap or would you direct me to someone who could?” or in bigger stores “Do you work in this department?”
Therefore, keeping all this in mind, the way in which you approach an employee may be all that is needed to start things off on the right foot. A smile, a validation of how busy the day looks, a statement of appreciation, or anything that would help you feel more comfortable if you were the employee and you were “overworked and underpaid.” This sounds like The Golden Rule. Why, yes it does! And while I try to encourage that behavior and paradigm in everyone with whom I work, I know the human factor will always kick in.
Thank you so much for reading! I hope this was as enjoyable for you to read as it was for me to write. See you next post!

Pharmaceutical Care

Sickness may abound:
Sadness and pain,
Swelling and strain.
There might be weakness,
Breathless moments
And terror.
Idiopathicities and strange opacities
Diagnosis X Y or Z.
Treatments that fail or win:
Can cause our minds to spin.

One treatment I know
That may not cure the physical
Is to see and to hear and to sense
What may never be said
And to hold your life as precious
beyond precious.
I lift you up, brush you off,
Despite rudeness or kindness
You are all significant
Worthy of love and respect.