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solareclipse2
May 27, 2009 2:11 PM
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Poor guy. All I can do is feel bad about his situation.

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1 replies
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SJActress
May 27, 2009 11:45 PM
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@solareclipse2:

Agreed. And while we're on the subject, why in the hell should this medicine cost so much in the first place? It's found in a fungus made by a bacteria in SOIL!

We have totally screwed up health care in this country. There's no simple fix, obviously, but something needs to happen.

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hills
May 27, 2009 2:13 PM
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Unfortunately, when there's a problem between an insurer and a provider, it is usually up to the customer to sort it out - very aggravating. It sounds like Chris will be getting his meds soon, which is good...

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2 replies
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Verucalise (Est.February2008)
May 27, 2009 2:39 PM
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@hillsrovey: What I'm questioning, is why they were double billing for these meds. Isn't that illegal, and why did it take 21 months for this problem to emerge?


CVS was billing 80% to Medicare and 100% to N.J.P.A.A.D.- Instead of checking their systems and seeing 80% medicare paid for and noticing the error, they decided to cut off the PATIENT? Apparently, customers come first... after money.


CVS, shame on you. No one asked you to donate meds, but you could of gone the extra mile to recheck your billing system. I'm sure this poor person wasn't the only person using N.J.P.A.A.D. at a CVS, which makes me question their entire billing practices.


Makes me love my small local pharmacy.

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Corporate_guy
May 27, 2009 2:32 PM
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@hillsrovey: It's a little absurd for CVS to not tell him anything about the situation for two whole years. It's nice they were willing to eat the cost for two years, but had they told him 24 months ago when the first payment was not made, he could have had two years to sort it out. Now he has 4 days. CVS clearly needs to fix it.

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VA_White
May 27, 2009 2:14 PM
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I hate when you have to know more about billing and procedures than the people who are paid to know about that stuff. I went through the same sort of thing with my doctor's office after surgery. I had to be the middle man between my insurance company and the nitwit in my doctor's billing office and tell them exactly what ICD9 codes to bill it under to get it paid. Why is it my job to tell her how to do her job? Why?

I feel for the guy. Hope he gets it straightened out soon.

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5 replies
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Eyebrows McGee (now with more baby!)
May 27, 2009 4:46 PM
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@VA_White: I have a high-deductible plan combined with both a health care savings account AND a flex spending account. EVERYTHING is supposed to be sent to the insurer first, who then remits it to the HCSA and then the FSA and THEN to me. Not many doctor's offices locally have dealt with these plans yet, so it ALWAYS involves a 10-minute argument with them. \"No, if I pay the co-pay now, it'll take two months for the insurer to pay YOU. You have to send it to them FIRST, and the co-pay will be remitted within 10 days.\"

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the_wiggle
May 31, 2009 9:39 PM
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@Eyebrows McGee (now with more baby!): Humana Access by chance?

sounds like what we have at my employer. the concept is great. the implementation - not so much. i'm finding that unless i set aside a \"spare\" cc to handle the expenses while the endless paperwork fights drag on & on, we wind in collections - constantly.

i'd take the old HMO style stuff back in a heartbeat.

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PappaBear
May 27, 2009 2:38 PM
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@VA_White: We all know many offices hire young women based on how well they look in a skirt and high heels - not on how compentent they are!

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solareclipse2
May 27, 2009 2:18 PM
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@VA_White:

I agree with you. Luckily my wife works in the medical field and I make her handle the insurance stuff. I handle everything else that's the deal.

Fortunately we haven't had anything that didn't get resolved right away.

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the_wiggle
May 31, 2009 9:37 PM
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@solareclipse2: wish we could say the same. we've spent 2 years fighting a billing problem triggered by the hospital my step daughter stayed in, being too stupid to stick to consults on the insurance & then lying about it.

we either eat the $900 & wait for DH's credit to heal or forget getting his credit over 600.

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Darrone
May 27, 2009 2:14 PM
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Who actually thought that this was anything BUT a CVS screw up? These people have way too much control over life and death for anyone to feel comfortable.

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JPropaganda
May 27, 2009 2:19 PM
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For some reason I don't think he's LOLling about this. I wonder why he put that in there?

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7 replies
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crackblind
May 27, 2009 2:58 PM
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@JPropaganda: Like Ted, I don't think he knows what LOL means.

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floraposte
May 27, 2009 3:05 PM
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@Lucifer_Cat: Yeah, I thought it was supposed to be a hollow, sarcastic laugh. \"Whoo, four whole days for my margin of error! I'm incredibly lucky!\"

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pecan 3.14159265
May 27, 2009 2:34 PM
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@JPropaganda: I was wondering this myself...I mean, maybe this is him turning a frown upside down, but I'd be really, really upset and also just a little bit afraid for my health if I didn't have a steady stream of medication that if missed, could potentially lead to poor health.

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nakedscience
May 27, 2009 2:52 PM
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@pecan 3.14159265: Just keeping his sense of humor or he might go insane? That's what I do.

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Liam Kinkaid
May 27, 2009 2:21 PM
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@JPropaganda: I think, in this case, it means \"Lord, oh, Lord\".

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Kryndis
May 27, 2009 2:19 PM
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Any chance he can simply transfer the prescription to someone competent?

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4 replies
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pecan 3.14159265
May 27, 2009 2:35 PM
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@Kryndis: I doubt it. My pharmacy won't give back a prescription because there's no record of how many times it's been filled. For all they know, you could take it to another pharmacy and have it restart so you'd be getting more meds. The pharmacy will always say you need to contact your doctor for a new prescription, and since they have records showing when they last wrote you one, and for how much, they can revise their prescription notes as necessary.

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bluewyvern
May 28, 2009 12:26 AM
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@pecan 3.14159265: Once a pharmacy has filled a prescription, that piece of paper becomes part of their records and they can't and won't give it back to you. What they can and will do is call another pharmacy and arrange a transfer of one of the remaining refills. The original prescription stays with the pharmacy that first filled it, and the new pharmacy writes out the info on a new piece of paper that they file as the transfer prescription. (The same as they would do if it were a doctor's office directly calling in a script over the phone.) The original pharmacy also indicates in their system that one refill was transferred out, which is subtracted from the total refills available. They definitely have a record of how many times the prescription was filled, either at their pharmacy or others.

In New York, you can only transfer one refill at a time, so if you need more than one refill transferred (i.e., are moving to another pharmacy permanently, not just out of town for the week or something), then it's usually easier to simply ask the doctor to issue a new prescription for the new location -- otherwise the new pharmacy will have to call up the old one to transfer a single refill from the original prescription each time it's filled, which is inefficient and time-consuming, requiring the attention of pharmacists at not one but two pharmacies. That's why they will ask you to contact your doctor for a new script.

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ThinkerTDM
May 27, 2009 4:14 PM
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@pecan 3.14159265: What kind of pharmacy doesn't keep a record of how many times it's been filled?
It seems to me they told you that so you wouldn't transfer your prescription.

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pecan 3.14159265
May 27, 2009 4:40 PM
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@ThinkerTDM: The pharmacy may keep a record, but they won't mark it on the script at all so they won't give it back to you in order for you to get it filled somewhere else.

Pharmacies don't talk to each other, so if I get my script filled at Rite Aid, and I want to take it to Walgreens, they won't talk to each other about it. Walgreens will take my script and maybe call my doctor...but more often than not, they'll just want to fill it and get me out the door.

I've had no problems with my pharmacy so far, but I remember asking once before to get my prescription back and didn't say why, and they still said no.

This isn't the same as when you have one script and you run out of refills, and have to get another script from your doctor and take that new one to a different pharmacy. I'm talking about having 5 more refills on a script that allows for 10 and deciding to take them somewhere else.

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GeekChicCanuck
May 27, 2009 6:56 PM
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@pecan 3.14159265:

Erm... don't know what pharmacies you're using but I've moved my prescriptions (with refills on them) between pharmacies several times - both within the same chain and between chains (or even outside of a chain to a small mom and pop pharmacy). It's never been a big deal and I've done this over many years.

They don't give me the prescription back - they just transfer the information. They've certainly never sent me back to my doctor to get a new prescription!

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Verucalise (Est.February2008)
May 27, 2009 9:02 PM
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@GeekChicCanuck: I've tried to transfer my daughter's prescriptions to the same pharmacy, just the closer one and they wouldn't transfer hers. They said they needed a brand new script from the Dr.

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damiangerous
May 27, 2009 5:26 PM
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@pecan 3.14159265: That's completely untrue. A good friend of mine is a pharmacist for Rite Aid, and my wife is on a variety of medications (which we fill at CVS for convenience). Pharmacies are more than happy to talk to one another and transfer scrips around. They'll also contact other pharmacies for you if they're out of stock and you need something right away to arrange a temporary fill there. My friend is on a first name basis with all the pharmacists in the area pharmacies due to how often they deal with one another.

While it's true that a pharmacy won't \"give a scrip back\", as in give you the original slip from the doctor, because that's illegal they are entirely capable and usually willing to transfer your scrip and all records over to another pharmacy.

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pecan 3.14159265
May 27, 2009 2:36 PM
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@pecan 3.14159265: Which is not to say that he can't contact his doctor to do this, but if he can't get to his doctor's office, or the doctor isn't in that day...I don't know that other doctors would look at a chart and simply prescribe medicine for patients they haven't seen.

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PencilSharp
May 27, 2009 3:24 PM
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@pecan 3.14159265: Really? I've never had a problem in moving prescriptions, although 1. I stick to chain pharmacies and 2. I've never had a $3,000 a month script (PTL)...

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katstermonster
May 27, 2009 2:21 PM
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I feel terrible for this guy, but I give him big kudos for doing the smart thing and not taking it at face value...asking for information and verification is important, even if it is the only recourse in some situations. I hope it works out in his favor!

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kewl132
May 27, 2009 2:24 PM
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I use CVS's Caremark.com for all of my kidney meds(Including Prograf) and never had a problem. But then I have Blue Cross Blue Shield.

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kewl132
May 27, 2009 2:26 PM
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Oh also he should only owe $60 which is 20% of 300.

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2 replies
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zentex
May 27, 2009 2:31 PM
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@kewl132: no, that ~$300 is 20% of the total cost.

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SJPadbury
May 27, 2009 2:41 PM
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@zentex: @kewl132: Meaning that the actual cost of not dying each month is about $1500.

(And walking across the street to any other pharmacy other than CVS.... *shudder*)

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kewl132
May 27, 2009 2:43 PM
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@SJPadbury:

Depending on how much he takes. I take 3mg a day of prograf and the Price lookup at caremark.com (CVS) is only $300 for a 30day perscription without insurance.

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krispykrink
May 27, 2009 7:30 PM
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@kewl132: 3mg? The standard dosing pill is 500MG. I take 1 Gram (that's 4 500MG pills total) twice a day. Want to guess how much it would cost if I had to pay for it out of pocket, on top of Cyclosporine?

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krispykrink
May 27, 2009 7:40 PM
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@krispykrink: crap. nevermind. In my low caffeine haze I got Prograf and my Cellcept confused. poop

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GenerousHelpingOf_GitEmSteveDave
May 27, 2009 2:29 PM
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Can't they send the NJPAAD to collections? Perhaps take them to small claims court?

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1 replies
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floraposte
May 27, 2009 3:08 PM
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@GenerousHelpingOf_GitEmSteveDave: Depends on the state law about what you can do to state agencies.

Illinois got so bad about reimbursements that they passed a law requiring the reimbursements to come with interest if they were too late. Things have improved since then, but a lot of providers won't wait for the state any more and want the patient to wait for reimbursement instead.

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kewl132
May 27, 2009 2:39 PM
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Oh here is the bad part: You can only be on Medicare for three years after you get a Transplant then you have to get private insurance because you have to take Prograf and other anti rejection meds for the rest of the transplants life(on average 10-20years).

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jadenton
May 27, 2009 2:42 PM
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This is exactly the sort of thing that wouldn't happen with single payer health care.

Also, if $300 just 20% of the cost? Are these drugs really $50 a day? Obviously the don't cost that much to make. Big pharma puts only 1% back into research. Lots of the research gets done at public universities on public money, who then sell the patents back to back big pharma.

In a single payer system, we could keep the drugs cheap. Or hell, in a sane system the public would continue to own the drugs it payed to research.

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RandomZero
May 27, 2009 6:46 PM
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@jadenton: On the gripping hand, it could easily be made sane were the industry to get together and create an organization that determines exactly who owes what and send them the respective bills. That's how I was told it works here in Canada when I got my health/life license.

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baristabrawl
May 27, 2009 6:36 PM
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@jadenton: I kinda agree with you, but it's not the answer for the USA right now. I would love to see nothing more than this happen, but it would be such a process and people would fight it every step of the way.

Before we start moving to a single payor healthcare system, we need to start education the ignorant that think it wouldn't work.

These are the same people who trampled a Wal-Mart employee to death for a $29 television set.

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emis
May 27, 2009 3:35 PM
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@jadenton: Also, if $300 just 20% of the cost? Are these drugs really $50 a day? Obviously the don't cost that much to make.

I've got 2 pharmaceutical reps in my family... both have million dollar homes and always show up in a new high end vehicle every year at christmas.

My grandmother is on an anti-cancer drug that costs over $3K/mo retail, she does not pay because she's older and it's covered by various federal and state prescription assistance programs (maybe even a veteran program because of her second husband) ...

It's disgusting that the pharma gets that much money from the public for life saving drugs and at the same generates such MASSIVE profits and astronomical salaries for their sales, marketing and executive employees.

Whenever I hear someone in the industry cry about the potential stifling of R&D should drug costs be capped I just look at my relatives, and the earnings reports of these companies. usually I feel like I need one of those $1000 anti-nausea pills jmujeff was talking about

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Anonymous
May 27, 2009 2:59 PM
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@jadenton: Program does cost 1500.00 a month. Its a supply and demand thing I guess. My boyfriend also takes Celcept another anti rejection drog along with the Prograf and it costs about the same. Its crazy!

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Tux the Penguin
May 27, 2009 2:47 PM
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@jadenton: Did you not realize that this was the government screwing up the payments? Sure, CVS was not billing correctly, but did no one over in New Jersey ever think to tell CVS \"Hey, you're only supposed to bill...\"

You might want to rethink your talking points...

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Liam Kinkaid
May 27, 2009 3:04 PM
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@Tux the Penguin: So now it's the state's job to tell CVS how to do their job? CVS doesn't even know how to do their job correctly and you somehow expect someone else to help them out? This isn't kindergarten anymore; when you color outside the lines, there's no one to hold your hand and help you do it right. The state provides rejection codes, if CVS doesn't want to follow them, then how exactly is this \"the government screwing up the payments\"?

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Tux the Penguin
May 27, 2009 3:08 PM
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@Liam Kinkaid: Did you not read the part about NOT PAYING FOR TWO YEARS? Is there a human there thinking \"hey, they aren't getting the message...\" And yet, these are the people you want to put in charge of our healthcare.

I just find it funny that you read this and want to blame CVS in total. I want to pass some of the blame to New Jersey and you find that wrong...

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Liam Kinkaid
May 27, 2009 3:23 PM
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@Tux the Penguin: I'm glad in your world it's okay to do your job wrong and expect someone else to go out of their way to help you. If my company sends out an invoice to someone and they decide not to pay, we get on the phone and find out what's wrong. After all, it's (supposedly) our money. Maybe we did something wrong, that's why they're not paying. CVS figures they're infallible because they can't be bothered to pick up the phone and find out why they haven't been paid. Either they don't care all that much about their money, they knew they were doing it wrong for two years, or they thought they didn't have a right to the money. With such an egregious billing error (billing 500% of the correct amount), I'm willing to bet CVS was just waiting to see if the state would screw up and pay them anyway. CVS wants their money, they need to take the initiative. It's not the state's job to do CVS's job for them.

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Tux the Penguin
May 27, 2009 4:25 PM
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@Liam Kinkaid: People are going to do their job wrong from time to time. Its human nature. But the rejection code might have been wrong... or no code sent. We don't have that side of the equation. So lets just assume that the billing clerk (who make at most, what $15/20 an hour?) keeps doing the job he's told. Yes, there should be some thinking supervisor to notice that this isn't getting paid. CVS is at fault.

But on the other side of the coin, some receiving clerk should have noticed that the bills coming from CVS are also being rejected. And if not him, then some thinking supervisor to notice that they are being billed for drugs dispensed but not paying. Trust me, that's always a problem.

Does New Jersey not have a fiduciary duty to fulfill their obligations? Simply hiding behind the reason of \"they were billing wrong\" isn't morally acceptable. What if the man had complications and died while all of this was being resolved... 21 months delinquent. Would we be singing the glories of a single-payer then?

Both sides are at fault. CVS for not abiding by the contract, New Jersey for not paying for ANYTHING for so long. They were putting their client at risk.

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coren
May 27, 2009 4:12 PM
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@Liam Kinkaid: In my world, if someone bills me for more than what they should, I deal with that. It's the state's job to pay for a portion of this - they've been delinquent for 21 months. It's not their job to correct CVS, but it sure the hell is their job to pay their share.

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Liam Kinkaid
May 27, 2009 4:37 PM
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@coren: In your world, if someone bills you for more than they should, and you do nothing (as the state did in this instance), no one calls you up on the phone? You fail to make your car payments or mortgage payments and you don't hear a thing?

Additionally, in your world, your creditors have specific remedies if you fail to pay, i.e. collections, damaging your credit, etc. In this example, however, CVS does not have any such remedy against the state. The state has no obligation to pay an incorrect bill and no consequences to not paying the bill, incorrect or otherwise.

The state knows this and CVS knows this. CVS chose not to contact the state about not getting paid. Not just once, but for two years. Twenty-four times they submitted a charge for the medicine and twenty-four times they were rejected, knowing all the while that they were not somehow going to get paid magically.

Einstein once defined insanity as \"doing the same thing over and over again and expecting different results.\" What did CVS think was going to happen? The burden lay on CVS to find out where their money was and the state of the insurance claim. They failed to do so and, instead of picking up the phone to find out the error they made, chose to punish a transplant patient. They didn't even have the common courtesy to tell the patient that there was something wrong with getting payment and that they would fill the script one last time before they would not be able to do so anymore.

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coren
May 27, 2009 4:50 PM
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@Liam Kinkaid: No, in my world I don't do nothing - because A) I'm not irresponsible and B) not doing so will negatively impact me. The state, in this case, was not negatively impacted.

Just because my bank doesn't do something about it doesn't absolve me of my responsibility to fulfill my end of the bargain - I agreed to do something (probably signed a contract!) so I need to do it.

Normal thinking in this kind of situation isn't \"Well, I'll just *not* pay the bill and go delinquent!\" People have no expectation their service will continue or the bank won't take action if they don't pay - they deal with the situation. Which is what should have happened here - especially with someone's life in danger as a potential consequence.

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Liam Kinkaid
May 27, 2009 5:07 PM
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@coren: If your bank does not do something, it doesn't absolve you of your obligation, you are 100% correct in that regard. Their failure to act, however, does not create additional obligation on your part.

CVS failed to uphold their obligation, which was to bill correctly. This did not create an additional obligation on the state's (and, by extension, the taxpayers) part to correct CVS's error. CVS, by accepting the right to bill the state for the 20% gap also accepted the responsibility to bill correctly. This is, in effect, a contractual obligation. CVS failed to meet their obligation.

If you look at the situation a little more carefully, and if CVS expected to get paid 500% of the agreed amount, it might even be constituted as repeated attempts to defraud the government (and, again, the taxpayers).

\"Normal thinking\" for a consumer/business relationship is not the same thing as \"normal thinking\" in a business/governmental relationship. In the first situation, the obligation to pay arises from the use of goods/services. In the second situation, the obligation to pay arises from the acceptance of a properly prepared claim. CVS did not submit a properly prepared claim, therefore the obligation to pay has not yet been made.

The state did not put the OP's life in danger, CVS did that. They're refusing to correct their insurance claim submissions, and requiring the patient to figure out what's going wrong. They are, in effect, shifting their obligation to the patient.

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jadenton
May 27, 2009 2:54 PM
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@Tux the Penguin:

Read the update. This is CVS screwing up.

But three things prevent CVS from getting this right. The first is that its staffed by people who work at CVS. Nothing to be done about that. The second is that there are two parties to bill. The third is that every patient has to be billed differently. If every patient was cared for by a single payer, the billing gets much simpler and potentially fatal screw ups happen much less frequently.

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Tux the Penguin
May 27, 2009 3:04 PM
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@jadenton: I worked for an ER billing company for years... the error rate in billing is MUCH lower than you seem to be thinking it is. Just look at it this way: if it was common, would stories like this be something to read about? No, it'd be another of \"they screwed up again.\"

See, here's the thing. When my firm gets a bill for something and its more than what we've negotiated (just went through this for our office suppliers), we make a copy of the relevant part of the contract and show an adjustment on their invoice. We send it back and work it out.

Here, New Jersey just decided to not pay. Not tell CVS that they're messing up. Not to pay what they owed (trust me, that would have gotten CVS's attention). Not inform anyone. Welcome to a bureaucracy.

The question you need to ask is how many \"errors\" are acceptable? There's an old saying:

Pick two: good, fast, cheap. You can only have two.

Right now we have a system that is more or less good and fast. Canada is good and cheap. Would you rather fast and cheap?

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floraposte
May 27, 2009 11:11 PM
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@Tux the Penguin: I'm in the US, but I'm not getting fast, and I'm not getting cheap.

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jmujeff
May 27, 2009 2:47 PM
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@jadenton: My wife takes a \"generic\" anti-nausea medication for her cancer treatment that costs about $1,000 for a months supply. We pay about $100 of that. \"Generic\" my ass.

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Ronin-Democrat
May 27, 2009 2:58 PM
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Yes anti rejection drugs are that costly.

Rule 1

Always refill script after 3 weeks so problems have time to be cleared up

Rule 2
Get to know the head pharmacist so that when there is a problem you have an advocate

Rule 3
Use a mom and pop pharmacy if your medications are life giving, they WILL treat you like gold

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3 replies
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pecan 3.14159265
May 27, 2009 4:41 PM
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@Ronin-Democrat: Rule 3 is not always possible. And I'm not sure a lot of mom and pop pharmacies carry life saving and expensive medications.

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Anonymous
May 29, 2009 4:31 AM
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@pecan 3.14159265: I work for a Mom 'n' Pop pharmacy. We may not have it that day, but we can have it the next day, just the same as the big guys do - and once you're registered with us, we'll always keep it in stock for you. Don't assume that CVS or Shoppers Drug Mart is the only way to go, just because there's one per block!

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Anonymous
May 27, 2009 3:12 PM
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@Ronin-Democrat: You can't refill a script unless you have less then 6 days dosage. Then they tell you you need a refill. Then they tell you you need a pre-authorization form sent into the medicare D carrier (24 pages!) Then they deny it and you need an emergency appeal form faxed from the doc to the insurance company. THen it all repeats...

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squinko
May 27, 2009 3:01 PM
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I can't understand why no one from the PAAD called CVS and told them not to bill them the full amount. Or why they never called Chris and asked him to take care of it at least.

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unobservant
May 27, 2009 3:02 PM
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I think that this is the first and only time I will ever see the phrase \"LOL I have 4 days of anti-rejection meds to hold me over.\"

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Daisuke Matsuzaka
May 27, 2009 3:05 PM
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As a person who had a liver transplant just over 7 weeks ago, I too take Prograf. I too work with CVS. I will keep track of those scoundrels.

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emis
May 27, 2009 3:08 PM
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Part of my kidney transplant evaluation was to prove that I could get my anti-rejection meds paid for. I know of people with full time jobs and what they thought was \"good\" insurance, get denied transplant surgery even though they had a donor only because they couldn't get the meds paid for!

Jebus tap dancing christ!

Is that true?

That's friggen' scary if it is... denied a life saving transplant procedure just because you can't prove that after you get it you'll be able to pay for your medication???

I mean, I can understand being denied because you haven't shown commitment to caring for yourself by continuing damaging behavior like continuing to consume alcohol, illegal drugs, not taking your prescriptions, showing up to doctors appts, etc... but not being able to prove your ability to pay???

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kayaknurse
May 28, 2009 1:37 AM
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@emis: I realize it may seem callous to verify the person's ability to pay, but let's remember, that not getting a new kidney isn't a death sentence. As a dialysis nurse, I can tell you that my patients can live many years as long as they show up for treatment (you'd be surprised how many skip) and take care of themselves (diet, blood sugar, blood pressure, etc.). The bigger problem I have is that we have so many people who are on the transplant list who smoke. Why should these patients get a kidney if they are just going to rot their lungs?

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squinko
May 27, 2009 3:17 PM
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@emis: You have to take that medication or there will be a rejection of the organ. It may sound callous, but they don't want to \"waste\" it on someone whose body will just reject it, much like someone who won't quit doing drugs or drinking alcohol.

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emis
May 27, 2009 3:26 PM
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@squinko:

Agreed... but I guess my point is that if you NEED a transplant, you also NEED the drugs, and the fact that you can't PAY mean you will die. I just assumed that if you needed a prescription like this and were not able to pay for it, you would qualify for public assistance--such as this fellow did via NJPADD and Med-B.

It's frightening to think that folks in the middle, who hold down $30-80K/yr jobs with private insurance might be DENIED a transplant because they can't prove their ability to PAY for a drug, yet do not earn little enough to qualify for the public assistance programs.

Scare thought for the average working American.

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the_wiggle
May 31, 2009 9:44 PM
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@emis: lovely layer of terror to add to the abysmal state of \"affordable\" care in this country.

it really truly is - have a sh*ttonne of $$ or just die already world :(

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DinnerBelle
May 27, 2009 5:04 PM
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@emis: The transplant center will do everything they can, including investigating eligibility for previously un-considered Medicaid/Medicare/High Risk state health coverage, in order to list a patient. We look into investigational drug coverage, as well as sign people up for pharmesecutical company assistance programs.


But as Squinko states, we have to make sure that a patient has ALL the tools to take care of themselves and their new organ. And that includes the necessary medications.


It is our goal to never have to not list someone for financial reasons.

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JaideepG2002
May 27, 2009 3:41 PM
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This is ridiculous, I hope they get this figured out properly. I mean if he doesn't get the med's a perfectly good kidney would go to waste.


These insurnace companies need to be punished and fined large amounts in the millions each time they are found at fault. I gaurantee you they'll stop pulling this crap.

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kathyl
May 27, 2009 3:54 PM
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Does this man (who I feel truly bad for, because no one should be jerking him around now when he should be concentrating on recovery) live in a small town where CVS is the only pharmacy he can use? Surely there has to be some better option, right? It seems wrong to reward CVS with his business once they get the billing straightened out. Capitalism is only supposed to work if we can vote with our feet and let businesses that are incompetent fail due to lack of repeat business.

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bigsam27
May 27, 2009 8:12 PM
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@kathyl: I have a kidney transplant and my insurance co. (BC/BS of RI) now forces me to use CVS/Caremark Specialty Solutions. I can only order refills by phone and it is shipped via US Mail. I am also limited to a 30-day supply, as opposed to a 90-day supply.

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morlo
May 27, 2009 7:55 PM
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@kathyl: Almost all smaller pharmacies (and medium chains) have been acquired by the 3 chains. And once a business is a certain size, they don't care--they are too big to fail.

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the_wiggle
May 31, 2009 9:46 PM
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@morlo: & thus \"voting with my/your/our dollars\" also fails.

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coren
May 27, 2009 4:14 PM
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@kathyl: To be fair, this is almost two years after the fact - how long is recovery for an organ transplant?

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catastrophegirl chooses not to fly
May 27, 2009 4:47 PM
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@coren: i have a friend who has had to have both a kidney and a liver transplant. the anti rejection drugs for the liver she got over a decade ago ruined her kidneys. so i know at least one person who has been on anti rejection drugs for over a decade. and i am pretty sure if she quits taking them, her body rejects the liver.

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Copper
May 27, 2009 4:41 PM
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@coren: I guess you don't watch any of the medical tv shows...from just those I know that you are on the anti-rejection drugs until you die.

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coren
May 27, 2009 4:51 PM
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@Copper: @sponica: Oh no I understand that, but I'm just saying it's not as if he is going to be any more recovered now, almost two years out, than he will in three or eight - it's not a recent surgery needing him to have bedrest or somesuch, he's probably out living his life.

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sponica
May 28, 2009 4:17 AM
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@coren: but it's better to be safe than sorry...anti-rejection drugs aren't exactly something I'd want to wait out until the billing is fixed.

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sponica
May 27, 2009 4:30 PM
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@coren: I may be wrong but I think you either need to be or can be on anti-rejection drugs the rest of your life...

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sponica
May 27, 2009 4:04 PM
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@kathyl: i wouldn't be surprised. I live in a town in NH of 20 or 30K people (not exactly small) but we only have one option for a supermarket. Shaws in the north side of town or Shaws in the south side of town....and Shaws won't relinquish the lease of a vacant building they have because they don't want someone else coming in to the town. They'd rather pay rent on an empty storefront for 5 more years than allow competition. And because they have no competition in the zone, they do not have lower prices.

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almightytora
May 27, 2009 4:01 PM
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The follow-up will probably include that this poor man has suffered worse symptoms and is suing CVS and PAAD.

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catastrophegirl chooses not to fly
May 27, 2009 4:17 PM
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contact the manufacturer of the medication and ask if they have any way to get him an emergency short term supply of the medication. they will also need a prescription to do this but it's likely his doctor will be up for that.
[disclaimer - what i just described is part of my job at another pharma company, not all pharmaceutical companies may have this option]

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catastrophegirl chooses not to fly
May 27, 2009 4:47 PM
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@catastrophegirl - manic first time home buyer:
\"For more than 10 years, Astellas has helped provide Prograf to several thousand uninsured patients who have experience financial hardship. In recognition of the growing financial need of transplant patients, Astellas has enhanced our Patient Assistance Program for Organ Transplant recipients, effective December 1, 2006. For more informaiton please call the reimbursement hotline, available from 9am to 8pm EST daily at 1-800-477-6472\"

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blue_streak
May 27, 2009 4:22 PM
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@ PappaBear : Was that really necessary?

If someone doesn't know how to do their job, it's a training issue, that is, management not doing their jobs. It's not a reason for you to snark on a whole group of people because society deems them sexually attractive.

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Anonymous
May 27, 2009 4:24 PM
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I feel bad for this guy, but this really isn't CVS's problem. It is his problem. The insurance plan he has with his secondary insurer has nothing to do with CVS. If they don't pay it, which they aren't, he is on the hook for the bill. Sure CVS was doing it wrong, but it is really his responsibility in the end. How does 2 years go by and he doesn't look at an explanation of benefits from his secondary saying they aren't paying anything?I think it is crazy providers are held responsible for payments on policies they have nothing to do with. If this were a single party system, this would not have happened. Unfortunately, insurance companies do this because they can.

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DinnerBelle
May 27, 2009 4:54 PM
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Chris, have you contacted your Transplant Coordinator regarding this mix-up? I know you are many months post-transplant, but they should be willing to help you.


S/he should be able to put you in touch with a transplant social worker and/or with the hospital pharmacy to get you a few days of extra Prograf so that you do not run out.


They may also be able to help sort out the issues with CVS. As you mentioned, they confirmed your ability to recieve the appropriate medications prior to transplant. They should have all of those records still on file.


Your Transplant Center wants to make sure that you have all the tools you need to stay compliant with your immunosuppression. They don't want to see you for rejection!! They would probably be happy to help.

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MedicallyNeedy
May 27, 2009 7:14 PM
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@DinnerBelle: I called CVS this morning, after the N.J.P.A.A.D. informed me of CVS's incorrect billing. Having explained the situation to her she said she would get back to me.
About an 90 minutes later, I get a call from the same pharmacist and she didn't have a clue of the previous conversation we just had and tries to explain that I need to pay the 20% not covered by Medicare B (almost $300).
She tries putting it thru again, (so she says), and tells me \"it's not letting me put it in!\".
I say, \"the computer is not letting you put N.J.P.A.A.D. in as the secondary insurance?!\",
to which she responds \"No\", Not being privy to last nights conversation, with the other pharmacist where it would get APPROVED but CVS Corperates' instructions were to the bill Me.
I said, \"print me out a rejection slip\", she said, \"It's not letting me do that either\".

I hear her talking to the other pharmacist and put on hold again.
The other pharmacist picks up the phone...
They finally found the right codes. I can pick up my anti-rejection med (Prograff) today. I'll need the $7 co-pay.

How much ya wana bet they'll tell me I need to come up with 21months of co-pays to get my pills?
(Plus another anti-rejection med (Cellcept) that I was also taking for about 16 months.)
I assumed they were not charging me because of the drug category.

I know the CVS staff are overwhelmed but I believe that I was lied to in regard to \"the computer is not letting me put it in\".
I have felt this on many other occasions. I see it happen to at least 1 of three people in line while I wait for meds to be processed.

To be continued I'm sure.

NJPAAD called me at 2:43pm and said they see the prograff went thru. Expressing a concern that I would have to pay for back co-pays, she said to tell CVS to call PAAD because I have been getting my meds under the PAAD card all along.

I want to know Who the CVS Corporate person is!
Isn't this Theft by deception(incompetence)?!
Callus disregard of human life?
Assault, in the least?!

If I were any sicker and not able to put up with these hurdles \"most every time I get my meds\", I'd be dead.

I'm happy to be feeling OK enough to be advocation for single payer insurance. I'll be in Philly Friday for the Healthcare Now day of action.

Chris

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DinnerBelle
May 27, 2009 9:02 PM
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@MedicallyNeedy: What a mess. I wish you the best of luck. It is a sad commentary on our health system that the sickest of us are the ones who run into the most difficulties.


As other commenters have mentioned, I would consider switching pharmacies. You have pretty good insurance coverage for a transplant patient and you should be able to find someone who will service you appropriately.


Not billing a secondary at the correct 20% copay rate is ridiculous and unethical. And if they accept Medicare payment, may even be actionable. Providers are not allowed to double-dip.

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Possinator
May 27, 2009 6:09 PM
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If he dies then it's a win-win for the corporates. The insurer no longer has to pay for the meds and CVS doesn't have provide meds they're not being paid for. See, it's a win-win for everyone....almost.

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baristabrawl
May 27, 2009 6:33 PM
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I am not blaming the OP but I do want to say that it is the insured's responsibility to make sure that the insurance is working the way it's supposed to. If not don't wait until you have only 4 days of a life-saving medicine left before you raise a stink.

I would most likely switch pharmacies and detail my experience in writing to someone else at CVS Ghost Central. If CVS can afford to make mistakes like this, then they can afford to watch me walk into a Target pharmacy. I'd even send pictures.

In summation, CVS is being douchey about their billing and that is CVS's responsibility. The OP might end up hospitalized because of their stupidity and I don't understand how you get this far behind on being paid before you just start denying someone their medicines. Really, CVS? Get your head out of your butt.

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MedicallyNeedy
May 28, 2009 4:12 PM
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@baristabrawl: I am forced to use CVS by my medicare D plan. You can not refill a medication when you have more then 6 days dosage left otherwise they will tell you \"Its too soon!\". when you call stop in the next time they may tell you, it needs a refill or it needs a \"pre-authorization\" which is a 24 page form the doctor's office has to fill out, or your insurance no longer covers this med... This all can usually be worked thru but at the expense of days, sometimes weeks gone by without the med.

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krispykrink
May 27, 2009 7:37 PM
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Chris, be prepared to make this fight constantly with your pharmacy and insurance, whether it's private or Medicare/medicaid. I've been doing it for over a decade and it's constantly happening.

If you're really down to only a few days left of Prograf call you transplant center or Doctor. They usually keep a supply of the various anti-rejections meds on hand for situations like this and can give you at least a weeks supply to hold you over until CVS pulls their head out of their ass.

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MedicallyNeedy
May 28, 2009 1:57 AM
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I got my Prograff but they screwed up my prilosec order. They did not bill PAAD again! When I came back after they reprocessed it they gave me twice the normal amount for $6 instead of the $7 co-pay. I know they restricted the amount to 30 days from 90 some time ago, but did they revert back without notice? Should I have had the doc write for 90 days all along?? They're drivin me nuts!

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othertim
May 28, 2009 5:50 AM
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Okay, here we go again. This is not a problem with the store themselves. The pharmacy submits the claim, gets an approval message from the insurance and charges whatever it says. The rest is supposed to be paid for by insurances. There is zero guarantee that the pharmacy actually gets paid by the insurance (though 99% of the time they do).

When there's dual billing involved, things get about 931% more complicated. Especially when medicare gets involved. To me, someone at PAAD should have caught onto this sooner than two years so that CVS wasn't effectively losing money on every single fill of the prescription.

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Selera
January 29, 2010 12:33 AM
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I work for a cvs and yes some insurances will allow a claim to go thru even if they wont pay for it. We had a guy who was supposed to be on workers comp and after putting vicodin thru for 1 year for a chipped tooth one of the girls finally called the insurance after the guy brought in a letter stating he owed them money. They stated his claims shouldn't go thru which we promply placed one thru to show her that there system was still allowing it active. As far as the above claim problem I would say have one of the tech call that insurance while your there and if they need to speak to you they can. A game insurance likes to play is have that patient call us. Insurance is just as frustrating on the people trying to run those claims for you as well. At times I just wish they would let it go thru an save everybody all the stupid hassle

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