So I'm at work, doing my thing, you know, professional tablet slider. It's about 4:30PM In comes a woman with a script underneath the all too familiar blue piece of oblonged paper everyone on the dole gets. They ask how long and tell me they will come back later. Then the patented "Worst-case-scenario-eva!!" takes place. The infamous "guy on medicaid with a script for non formulary antibiotic that was seen at WVU hospitals by some random PA on a Friday that is just now handing it to you LONG after the prescriber has gone home for the weekend" scenario. The Rx for Widdle Kidd, an infant: Widdle Kidd - 1/23/05 Ceftin susp 250/5 2.5ml q12h X 10 days Disp: QS M. Wacko - P.A. So using my magical Intern powers, I deduce that she probably has an ear infection based on how flippin' big the dose is for how much I assume she weighs. So I decide to see if Augmentin ES-600 can be billed to medicrap, and, yes, it can. It's about 4:40PM With my battle plan in order, I call the hospital to start my daunting, epic journey in search of the mythical "competent human being." Oh, they exist, I've talked to them. They are just elusive. Like trying to find an honest used car dealer or a prostitute that isn't really an undercover cop. Trying to find them can lead you down paths of deception and anguish, but when you find a good one, it's like a rush of visceral pleasure. Finding that person that can give you the DEA number of the mystery resident that wrote a Percocet script is equally as rewarding as being named a Rhoades scholor. It's a game. Where's Waldo for the pharmacy set. I just imagine the infectious disease resident I'm probably going to have to talk to wearing a red-and-white striped outfit with a thick pair of black glasses and I'm set. You're mine Waldo. So I call the number on the PA's script. The first thing I get is the stupid message I have burned into my head I am told they are gone for the day and am directed to the hospitals confusing main telephone system. I've learned that mashing buttons indiscriminately will generally get you a person, so after hitting a combination of 3 and 6 40 times I'm directed to the help line. The person answering the phone is one of those 1st week receptionists. I give her the usual rant and she redirects my call. After a few rings I get an answer, "Cafeteria. Rob." The moron redirecting the call obviously screwed that one up. Out of annoyance I acted like I didn't pay attention to his greeting and just started rattling off, "Hi, Mike, Sabraton Pharmacy, I have a script here froma PA down there that I assume is for an otitus media infection, but it isn't formulary on the patients third party, I was wondering if we could discuss a therapeutic substitution." After what I SWEAR was like a solid 10 second pause, the guy just kinda grumbled somthing and hung up. Now it's 4:55 PM. Square one, nice too see ya again. I call back and this time I'm connected to the ID resident. After my canned introduction speech I tell her that I'm pretty sure it's otitus and that a good switch would be to Augmentin because it's first line and, more importantly, paid for by my precious tax dollars. She goes to get the chart. I'm on hold for about 10 minutes counting out Lortab while listening to that damned piano tune they have for their hold music that I can't get out of my frickin head. As I'm waiting one of our 'problem' customers brings in a script for OxyIR and I notice that he is appearently "allergic" to naltrexone because it was added to his profile yesterday. Hahaha. It's 5:10PM The resident comes back, "The chart just says cough/congestion. I don't know what she has." Using my powers of persuasion (i.e. using big, multi-syllable words) I convince her that it's probably otitus or sinusitis and that she should go with the 90mg/kg Augmentin regimine because it's really awesome......and paid for by medicaid. So, logically, I ask for a weight. She replies, "I dunno, it's not in here." So I just say, "Ok, fine, how about this, I'll ask the parents the weight, 90 per kg daily over two doses for 10 days, cool?" She then questions me on the otitus being 10 days asserting that it's 5-7. Oi. I'm frickin' looking at my little manual that says 7-10, so without getting into a superiority battle, I just say, "ok, we'll do 7 days, then." I hang up and it's 5:20. So I'm victorious. I've got a script that will work and all I need is the kid's exact weight. An hour later, the parents come in to ask me where the medicine is. After getting the kid's weight and confirming it's an ear infection (haha, I was right.), I tell them it's going to be a few more minutes. Then it happened. They just had to say it. That annoying, annoying phrase. "It's not done yet? I gave it to you two hours ago, how long does it take to put water in a bottle?" They know they don't have to say, but they do anyway, just because they can. It makes you want to throw a computer monitor at their heads. Or maybe stab them in the carotid with an insulin syringe. Maybe not kill them, but certainly maim them. I stayed calm. God knows how. I just let my blue coat reconstitute the bottle and ring the guy out. The pharmacist explained that we had to call and get it switched, they didn't really seem it appreciate it. An hour's worth of work and all I get is a bunch of crap. Grrrrrr, I say....grrrrrrr.
hell-freakin-yeah! stupid medicaid and stupid er and stupid pa's. unfortunetly that is real life pharmacy. i would have personally seriously debated throwing the augmentin at them at that point and why is it that if the patient is public aid and you make a large switch for them and then tell them about it they always want the other med not covered and don't understand why it's not covered.
what's wrong with regular amoxicillin? Most ear infections clear w/o AB anyways so way waste some expensive amox/clav? I've heard that ceftin oral susp tastes horrible
You can't expect everyone to know what drugs are on the Medicaid formulary. You yourself had to check and see if Augmentin XR was covered. Also, npage is correct. There isn't really a good a reason to go with higher cost and higher side effect amox/clav over amox unless amox has failed. You also can't expect people to be grateful when you fix a problem that is beyond their understanding. You have to educate them as to what your job entails, without being judgemental at them for them not understanding without your intervention. If you explain in a kind manner that there was a coverage problem and that you did alot of background work to resolve it, but still need the kid's weight to determine a safe and effective dose, 99% of patients, including those on Medicaid are going to be agreeable. And, next time they come back, they are more likely to be understanding if there is a delay in the filling process, because they know a bit more about what your job entails.
The first line emperic therapy is usually high dose amoxil and if that's failed, you bump it up to ceftriaxone, augmentin, or 2nd gen oral cephalosporin ( I think, I'm going off memory.) I assumed that because she wrote for ceftin, it was the 2nd go around. Turned out I was right, too.
Oh no, you don't understand, the pharmacist did. They were bloody ungrateful. And I defend my decision to use Augmentin because I didn't know if the kid had been seen before or not, neither did the resident - and it turned out he had, actually. But the cost thing went through my mind, too, but the PA wrote for Ceftin - usually reserved for Amoxil failure, right? Better safe than sorry, anyway.
For resistant otitis media, we were taught Augmentin for 3 to 5 days is good enough. Increases chances for compliance for shorter course antibiotics, which is usually low in lower socioeconomic populations. There haven't been much if any data saying whether 7 to 10 days is really worth it. We occasionally get that person who complains about the wait after all the work you do for them, but usually that's because they have other problems. Our pharmacy sees a lot of Medicaid patients, and 99% of them are really appreciative after you explain how you actually called the doctor so they could get the medicine or else it wouldn't have been covered and they would have had to pay the true out of pocket price.
Well, the nice bit about failing amox was important info to leave out. Alot of times, pa/md/np's dont follow guidelines, they just write for wahtever they think is cool/what pen they have in their hand. I guess the medicaid people in NY have it lucky, baiscally the only thing medicaid doesnt over is tigan, combo cough syrups (they only cover robitussin DM), second generation antihistamines and PPI's (besides prilosec OTC) needs PA. I guess thats why NY spends the most in the nation on medicaid
So it's ok if the person writing the prescription just picks whatever antibiotic they feel like? Leave it to the pharmacist to sort out? They always do anyways....
Prescribers have as little responsibility for carrying around insurance formulary booklets as we do. The should (obviously) pick the drug of choice unless they know it's not covered or there are contraindications. They didn't create the insurance formulary and don't typically have access to it, so I don't see why they should be blamed for the lack of coverage. If you accept insurance, it's a given that this sort of scenario is going to happen. In a way, we have brought the problem on ourselves. I personally choose to suck it up and accept that resolving formulary issues is part of providing good patient care. Getting upset at the prescriber is just ridiculous.
I'm upset at the system. Imagine how much easier it would be if they just wrote out a diagnosis and gave us an order to treat with such and such drug within a class. Can you imagine how much easier the job would be if they just wrote: Dx: GERD Rx: PPI, insurance formulary 1 mo supply 3 refills Then we could just fill for whatever it is express scripts covers that week and move on. It will never happen, of course.
That would totaly work! Imagine dx:major depressive disorder rx:ssri dx:schizophrenia rx:atypical dx:insomnia rx:benzo
That would irritate me too, it's an often thankless job. Of course prescribers don't know the formulary of every third party plan, but I don't think having a Medicaid formulary reference on hand is such a wacky demand. I have to wonder why people here have to be so goddamn disagreeable all of the time? It's frustrating to be unappreciated even with no reasonable expectation of being recognized.
[ I have to wonder why people here have to be so goddamn disagreeable all of the time? It's frustrating to be unappreciated even with no reasonable expectation of being recognized.[/QUOTE] I am wondering the same thing. SDN is not the same as it used to be a year or so ago. People are not very respectful or considerate anymore. Very combative.
We have a therepeutic interchange program in WA that lets us do that for certain prescribers and certain patients (ie: state sponsored plans and prescribers who sign up). It's nice for some things, like PPIs. But, for most of the other drugs, it's a huge PITA. Basically, instead of tossing it back to the prescriber if there is a problem, we are supposed to pick and dose a therepeutic equivalent. I hate being asked to do this without access to the patient's pertinent medical history. And, I worry that proper followup by prescribers will be lacking.
A formulary might be useful in a community clinic. But, usually prescribers don't know who is or is not on Medicaid during their visit. I don't think our Medicaid system issues formulary booklets here. If they did, they'd be useless by the time they were shipped out. The formulary is subject to sudden capricious change. And, they pull crap like stating that Toprol XL is a preferred drug while simultaneously insisting that it requires a PA.
Thank you. I could not agree more. I used to enjoy reading here but lately the content is far less informative and a lot more silly arguing from the few people left not afraid to post.
I honestly dont think that SDN has changed all that much. Perhaps because when I first started posting I was in pharmacy school, it has never really been all that informative to me... More... entertainment than anything else really I thought that the pharmacy forum would actually be informative but again... its not.. its mainly a forum for discussing current issues and opinions on those issues. I actually stopped using the forums for a while (6 months- year range) because it was such a hassle a few months after i first joined.. I have found that typically people dont like for you to disagree with them and get their panties all in a wad when you do and become combative. like i said... entertainment value nothing else... oh and so my post is relevant.... its too bad we cant be like hospitals with medicaid patients.... automatic substitution baby!
Thats how i became i freakin alcoholic!!.......yes those retail days sound the same. all i got to say to you younglings STAY THE FREAKING HECK AWAY FROM ANYTHING THAT RESEMBLES RETAIL.
Thats how i became i freakin alcoholic!!.......yes those retail days sound the same. all i got to say to you younglings STAY THE FREAKING HECK AWAY FROM ANYTHING THAT RESEMBLES RETAIL.
SDN Mobile is now free on iTunes and on the Google Play Store. Enjoy!Dismiss Notice