The Ambien Prior Authorization

Dear new RPh's and techs,

A post for my retail pharmacy people and those insomniacs whose insurance refuses to pay for sleep pills.

Just about the middle of last year, I started to notice that refills for zolpidem, generic Ambien, was being rejected for a prior authorization. This means that the insurance company wants to talk to the doctor to make sure that the patient really, really needs the medicine. What it really means is that insurance companies are the spawn of the devil and don't want to pay for anything.

A quick note about insurance companies: their business model is to take regular premiums from their customers and find ways to NOT pay out claims. One of the sneaky ways they do this is to send out brand new cards every year so that they can expire the old ones and hopefully not pay for a refill. In doing so, they make my job sucky for a few months out of the year, even more than usual with having to deal with insurance.

Most of the time though, their prior authorizations (PA) are well founded: rejecting an ADHD med for a kid who is 4 years old (my goodness, are we going to pump 1 year-olds with Ritalin next because they cry too much? wait a minute, we do! *sad face*), rejecting Cambia(R) because it's glorified ground-up diclofenac*, and rejecting Nexium(R) because it's basically rehashed omeprazole whose patent had run out**.

To these situations, I must say to the insurance co's, 'Nicely done. If I had more time to talk to the doctors to convince them to use medicines judiciously, I'd do the same. But since I'm here to dispense drugs pursuant to a prescription, I'd really wish that you'd make my life easier and just approve the medicine for a $200 copay so I can tell the patient to take it or leave it or take it up with their insurance/doctor. Because a PA makes it look like the pharmacy is being withholding, when it is in fact, you who are the angry wife (who is withholding of the marital obligation). Thank you.'

But I just don't understand when they reject meds which are comparatively dirt cheap (in the $40 range). Branded Lamisil tablets used to be prohibitively expensive, but the generic isn't too bad. Come on, guys! Let the old dude have it for his onychomycosis! Or when they rejected generic zolpidem when they had paid for it the first couple of months.

But then I remembered the lecture I gave on sleep disorders shortly after I graduated***: Ambien is FDA-approved for 'short-term treatment of insomnia characterized by difficulties with sleep initiation. Ambien has been shown to decrease sleep latency for up to 35 days in controlled clinical studies.'

Bingo! The resident medical 'expert' at the insurance department picked up on the little bit of important information (the package insert that accompanies the drug bottle), and found a great reason to reject refills of Ambien. 'Dear Dr. so-and-so: As you can see from the package insert, Ambien (Zolpidem) is not approved for treatment lasting longer than 35 days. Thank you.'

Anyone with any bit of reason (even insurance companies) knows that Ambien doesn't simply stop working after 35 days because the drug isn't approved for long-term treatment. It simply meant that Sanofi-Aventis didn't have the money to run the trial longer or were afraid that the sleep-inducing effects would wear off after 35 days and would lead to not-so-good-looking clinical results. As such, the drug is FDA-labeled for short-term treatment and now insurance companies have a perfectly valid reason to reject a claim using a prior authorization.

They could run longer trials now, but they won't because Ambien is generic, so they couldn't re-coop their expenses.
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So why know all of this? Because it is always better to explain to customers how it really isn't your fault. When you pass the buck to other folks, preferably drug or insurance companies, customers can get angry at them instead of at you. By the way, don't pass the blame to their doctor, because they may really like their doctor or their doctor may call and chew you out.

'Why is my insurance not paying for my medicine?'

*Smile* 'Well, sir. Ambien is not approved for long-term treatment of insomnia. Though I realize that you've been using it for years now, the original studies approving the medicine was only for short-term treatment. I think the insurance company wants to run this by with your doctor and make sure that there isn't a better way to treat your insomnia.'

Congratulations! The customer is no longer angry at you, and thinks you're pretty swell for your insurance knowledge. He shakes your hand, happily pays the ~$40 for the cash price of Ambien, and will take it up himself with his doctor/insurance.

Based on a true story.

Incidentally, you could also recommend the customer to get a prescription for Temazepam (generic Restoril) which is only about $20 per month without insurance.
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*I wanted to tell the patient to get a prescription for diclofenac 50 mg, buy a mortar and pestle, grind the pills up herself to put in water, and save $200 for 5 friggin packets!

**Please explain this to me: Omeprazole 20 mg and Nexium 40 mg are the most commonly dispensed strengths. We are made to believe that the S-enantiomer is supposedly the more active (or only active) component of the racemic mixture, and/or that it has less side effects. Therefore, if Omeprazole 20 mg contains 10 mg of the S-enantiomer (Nexium) and 10 mg of the R-enantiomer, wouldn't the equivalent strength of Omeprazole 20 mg be Nexium 10 mg?

So why does AstraZeneca market Nexium 40 mg which would be in essence, a four-fold increase in strength vs Omeprazole 20 mg (Prilosec, which they made)? Don't give me some BS about how there are fewer side effects so you could give a higher dose--show me a person who was taken off omeprazole for side effects and I'll show you a hypochondriac.

***Excuse the not-so-subtle reference to my genius :)

Po-po Predicament

Dear 5-0,

I have to think that the only people who love (traffic) cops are friends/family of cops. And even they only love the cop(s) that they know. Because people usually dislike those who have authority over them.

And cops can pull you over for any reason, and are in fact pressured to pull you over to increase their numbers/metrics. That's not cool, but This American Life is cool, liberal-ish cool. This 'cold front' hitting the Gulf Coast is mildly cool, but Ira Glass & crew are uber-cool. Anyway, check out their weekly podcast.

Not like it matters to me much. Since I hardly speed because I find my Corolla sitting on 14" starts to creak and shake above 70mph. And I find the gas mileage is insane when put on cruise control at 60mph (yes, I'm the jerk in the right hand lane chilling at 60mph, listening to podcasts on long drives because I like to not have to be on the lookout for cops sitting under bridges or just over hills).

But when I start to hit the greater Houston metro area, I turn off my cruise control and start driving attentively aggressive like everyone else. Because if you're doing 60 on a Houston freeway and it's not rush hour, you're bound to almost get slammed by some large truck bearing the flag of Texas and/or Mexico. Or an old caddy driven by grandma. Or a Lexus LS driven by Asian grandma. Or Charger/300 driven by middle-aged African-Americans. Or Infiniti Gs/Nissan Zs driven by Asian males. Of which, the latter two groups are rolling on glimmering dubs or dubs+.

But at least you don't have to worry too much about the nicer sports cars because the drivers care too much about their whips to get into accidents with your jalopy. When they cut you off, they know that they're not in any risk of messing their paint job--if you get distracted/pissed and wreck your car, then that's your fault. That's just my take, since I'm hopefully going to be upgrading my vehicle soon.
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So when US-59 turns into 3 lanes somewhere around Grand Parkway, I turn off the aforementioned cruise control, because [stuff] starts to get stupid with these idiot drivers. I caress and careen the steering wheel and the car, respectively, to avoid the speeders and the tortoises. I check out the cop sitting under the bridge in his light-grey 'POLICE' on white cruiser--Impalas (and moderately priced American cars) without rims are dead giveaways. I take the Beltway exit and check the rearview to make sure the 'Scalade behind me slows down a bit while he's checking out his shades in the mirror. Some people can be so narcissistic, not that I'd know anything about that (end sarcasm).

Then I take the first exit off the Beltway because it's the last free exit. I still haven't gotten the EZ tag yet, which I really should, considering I'm not poor anymore and can afford the couple bucks to avoid those atrocious Beltway feeder lights (which are synced so that you hit every damn one no matter how fast/slow you drive). My parents paid upwards of $10 to cross a bridge in NYC when we lived there; I should feel thankful to pay a buck-fifty to avoid some traffic lights.

And then just after the Hwy 288 intersection, I get a bit of amusement. Just some background about this tollroad: the Beltway 8, aka Sam Houston Tollway, completely encircles the greater Houston Metro. It costs about $1.50 to make it through an 1/8 of the circuit which is around $12 to make a complete revolution, which would take you a couple of hours (though I don't know why you'd do that except if you were a Nascar fan). The feeder, or frontage road, which runs adjacent to the tollway, is completely free, but depending on the section can have a crapload of lights. With the exception of going over the Houston Ship Channel and some other spots (I assume), you can use the frontage road and just pay with your time wasted on the lights. That is, it's free if you've got some time to kill.

Houstonians have made it a habit of killing time and the environment to save some coin. So the Beltway feeder can be packed at times. And it's only 2 lanes which wouldn't be a problem if people followed the generally accepted rules of a 2 lane highway, which the Beltway feeder mimics: slower traffic to the right, left lane for passing only.

I think in smaller towns and country roads, left-lane-for-passing-only is a law and you can get ticketed. But not in Houston of course. So all the time I see jerks driving the speed limit in BOTH lanes next to each other, not letting people pass for a good couple of miles. I've decided that it's usually because they're not paying attention to their surroundings, and not because they're vindictive a-holes. Chalk it up to my naivete or hope for humanity.

So when it happened this time around, I wasn't surprised. I just turned up Katy Perry's Teenage Dream on the radio ('yea girl, I think you're pretty without any makeup on, now can I put my hands on you in your skin-tight jeans? ;)') to turn down my frustration. But then I noticed the cause of this vehicular rudeness: a cop car.

I pass by a speed limit sign: 50 mph. I look at my odometer: 50 mph. I look at the cars: 50 mph, deduced by using relational physics. In redneck speak: 'He goin 50 cuz I'm goin 50 and I ain't passin em like Dale Earnhardt.'

And the cop just tailed them for a few miles, and finally got to his turn off the feeder. He seemed pissed because he got halfway into the left lane, but then decided that the other car wasn't going to speed up or slow down either. And it's not like he could pull them over for any moving violation: they were obeying the law--50 mph. But the cop knew and the two cars in front of him knew and I knew that everyone drives 65 on the feeder if they're under 65 (years old).

That's that. I guess this would be a Seinfeld-like post, an episode about nothing.

Whoa whoa whoa...

Take it easy…

First off, I hate censoring people. I hate censoring myself, but there’s stuff you don’t want people to read about you (stuff like how I think Leprechauns are real and that if I find one, I would trick it to show me where its pot of gold is so I’d never have to work). Whoever seen the leprechaun say yea!

I am a non-confrontational kind of person, and when I see or hear gunfire, I instinctively run the other way. That’s what real people from the ghetto do. So if there’s a squabble, I like to get as far away as possible, get some popcorn, pull up a chair at a safe distance and enjoy. But as this fight has broken out in my own house (aka blog), I have to respond. On a sidenote, don’t let people get plastered in your own house (thank you to all the people who have cleaned up after me! I owe you one!).

The one lesson I’ve learned as a retail pharmacist is that getting angry with people does absolutely nothing to help with a situation. You only irritate them more and you expend a lot of energy by having to quell your emotions after the confrontation. Don’t do it. Step back, breathe, and relax. There’s absolutely nothing anyone can do to you that will hurt you if you don’t let it affect you. Take their weapons away from them, and they will have nothing with which to fight. Some lady called me ‘withholding’ because I wouldn’t let her touch the tablets, another guy said I didn’t do my ‘due diligence’ because I neglected to process his discount card, a third called me ‘racist’ because I didn’t ring up her OTC med immediately because I was busy with hospice prescriptions. Whatever. Go on and brush your shoulders off.

A battle not fought is a victory won.

So to directly address the situation: did eggs’ comments affect me? Sure, but I have built my foundation upon my own self belief, that what I do and write is my true self (excluding stuff that would be TMI). And though that true self may be narcissistic, prejudicial, superficial, and arrogant, it is also humorous, light-hearted, deep-hearted, middle-hearted, and educational. Though I do not know if I am ‘good’ (or if human beings can be ‘good’ or if there is such a thing as ‘good’), I try to be ‘good’. Therefore, when anyone makes ‘attacks’ on my character, whether real or imagined, I have confidence in my attempted goodness. Thus, nothing anyone can say or do will have power over me (up to a limit, of course).

Upon this rock of my self-worth, I have built the temple of my mind.

So I shrugged off the ego-deflating comments. I cannot control others’ thoughts; I can only control my response to them. And when the comment feud broke out, I found it insanely comical because it was a (relatively) unnecessary fight.

But since peoples’ feelings have been hurt, and I foresee some escalation, I’m going to end it. I don’t trust that people have my prodigious fortitude (don’t you dare make a comment about my weight!) to deflect criticism. Because after all, we all know that I’m pretty much a big deal. :)

So keep enjoying my blog. Keep commenting on what you like or what can be improved. Posts are also forwarded as boxes on my FB page, so you can just hit the ‘LIKE’ button there. After all, I live off of comments because I am a narcissist, but do keep them positive or playfully insulting. Anything else will be removed. Call me an idiot but do it with a smile and temper it with something like how my tie has the most perfect dimple and drops exactly to mid-belt buckle or how you’d have to sue me for retinal damage because my Gucci is so sparkly.

Life is too short to live it angrily. If anything I say comes off as vaguely insulting, understand that I do it with a smile, and that I aim to offend everyone equally and myself especially. After all, the story of blonde 9.7 was not my proudest moment, but I shared it with you all (and you must admit that it was a pretty funny story at my expense).

People should die with stupid grins on their faces. That’s how I want to go, facilitated with loads of friends (and morphine). It’s a celebration! Enjoy yourself.
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On second thought, this isn’t Cuba or China. There is free speech after all, and you can do whatever you like (insofar as it is what I like). But as Catch-22 says, I have the right to do anything you can't stop me from doing. I am a delightful tyrant, but still a tyrant in the tradition of Nero (except without all that in-bred perversion), and this blog is my despotic realm.

So keep it above the belt or you’ll find your comment trashed. And don’t recruit people in your fights. Agreed?

Expired Milk: Where's My Money?

Dear yogurt lovers,

Let me preface this post with a description of a very common annoyance that has been happening to me this year. As a strapping single bachelor with no one to care for except me-myself-and-I, I have been remarkably good at not taking care of my sole ward. Sure, I handle the major things like keeping a roof over my head, wearing a seat belt and protection, etc, but diet, exercise, and sleep have been woefully neglected, like the red-headed step-child.

So I buy a gallon of non-organic (I like it hormone-laced!) fat-free milk about once every two weeks, resolving to have my daily 2 glasses of leche like the really smart people on TV suggest. But eventually, at the end of those two weeks, I’ve had about 2 glasses total and only because I felt like having something to go with my Lucky Charms. And at the end of those two weeks, I’ve felt really bad about eating Lucky Charms, so I get the 100%-daily-vitamins-and-minerals cereal which has about the consistency and taste of soggy cardboard. But where I epic-fail* is that the milk is two days past the ‘BEST BY’ date. Have you noticed that it’s not an expiration date, but a ‘BEST BY’ date?

Anyway, I pop the plastic cap and brush off the dried white flakes from around the rim of the bottle. A quick sniff reveals a faintly acidic odor not unlike the smell of plain yogurt. The milk flows freely when I shake the plastic jug, and there’s not much sediment; I think those are good signs. The cardboard cereal is already in the bowl looking very unappetizing, and it would be a chore to finagle the damn thing back into the box.

Oh well. I tip the container of fermented milk, watching it slosh gently over the wheat flakes. Thirty seconds pass, and I take another whiff wondering if letting the milk rest would improve its bouquet as if it were some fine wine. But like Olde English**, it’s best to hold your nose and gulp it while it’s still chilled.

I didn’t know what was more revolting, the milk or the cereal. But like a kid being forced to eat his vegetables, I willed my way through, spoonful by spoonful. After what seemed like torture comparable to water-boarding, I make it through the ordeal somewhat intact. And I felt good about doing well for myself and for not wasting milk.

But the warm fuzzy feeling subtly morphed itself into ominous gurglings and severe abdominal cramps. It felt like the time I had the ‘bottled water’ in Mexico. But the pain subsided, and being a stupid male, I sloshed another glassful of that drank down my throat instead of into the sink. But it wasn’t all that bad. The natural acidity of age added character to what would otherwise be a boring beverage.

So this post is like my expired milk. It doesn’t quite fit into the time frame, but it’s still good, and if you drink it with an open mind, it is quite palatable and surprisingly tasty! But don’t sue me if you get an enteric infection.

DISCLAIMER: g neither recommends nor condones eating or drinking of expired foods and/or medicines.
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Chuc mung nam moi! I’m too lazy to put all the Vietnamese diacritical and accent marks on the greeting. And if I did, it may not display correctly on your computer screens anyway. Basically it means, ‘Happy New Year’ in Vietnamese. February 14 this year happens to be the lunar new year as well, so the Asian folks in red garb are pulling double duty with VDay (red is a lucky color). There will be plenty of new years to come, so I’ll defer the description of the festivities as next year’s will likely be similar to this year’s. In Vietnamese, the word for new year is ‘Tet’.

Suffice it to say that there is plenty of booze, gambling, and luck-mongering. And for most kids, plenty of red envelopes, known in Vietnamese as li xi, filled with crisp, nice-smelling bank notes. There are a lot of traditions around it, but the only important one is that old(er) people give money to younger folks as long as the recipient is unmarried.

According to the repository of all knowledge***, both good and poorly-sourced,

‘In Vietnam, lì xì are typically given to those who are younger as long as they are bachelors’

Damn straight! I’m a bachelor and will remain so for the foreseeable future. So where’s my money!?

Now my extended family isn’t rolling in dough like some Asian folks are, but I’ve managed to scrounge up at least $100 in past Tets. Just for comparison, some of my friends rake in $500. I’m not that greedy; I just want a little something--It’s incredibly satisfying to not spend your own money.

So what was the count this year? A bill? $75 or $50? Nope, not any of the above.

It was a measly $35, and $20 was from Mama since she was in a giving mood this year. I can’t even get a shirt at Express for that amount!

I blame the recession! Young Asians everywhere should lobby to siphon CEO bonuses to compensate for the slimming of red envelopes around the nation. It is all very unjust! I am outraged and appalled that Obama would let me suffer a loss of ~$65. My new job and the fact that I don’t really need the money have nothing to do with it. The United Auto Workers didn’t stop fighting for higher wages when GM was going under, and I won’t either!

I’m just being facetious as always. My indignant resentment is all in good fun. I had a great time hanging out with the family, and that is far better than any amount of money.
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*epic-fail – the (bastardized) verb form of ‘epic failure’
**what do you know about that malt liquor?
***Wikipedia

Going Postal

Dear online-shoppers,

I've grown to become moderately patient over the years from my brash youth. I order stuff online and can wait to have it be delivered a week later because I know it is what I want (a specific type of iPod case). What I can't stand is post office idiocy and purported use of 'improved' delivery services.

One of those things is UPS Mail Innovations. How it works is UPS (United Parcel Service) mails the package to the USPS (US Postal Service) regional processing center closest to your area, and then USPS takes it and delivers it. It's supposed to streamline the process, and your package should be received sooner. It sucks, and it tosses salads.

My package shipped from Atlanta on the 7th, arrived in Austin on the 11th to the regional processing facility. It was forwarded by USPS to somewhere in Oklahoma City, bypassing Dallas completely. And now it's somewhere in limbo with a 'The U.S. Postal Service was electronically notified by the shipper on January 11, 2010 to expect your package for mailing'.

I'm pretty sure UPS or USPS by themselves could have gotten the package to me quicker without the other guy. Though 'working together' sound so much cooler, it really amounts to a longer wait time and more risk of packages being lost.

I guess I should be angry at the merchant for using such a retarded shipping system. I did order the damn thing on December 29, and my iPod is yet condomless.

GTA III is missing postal workers. I just want to talk to them nicely...with a rocket launcher.