Personal Pharmaceutical Benefits Management Rant

The Pharmaceutical Desert grows…

So, I’ve been getting messages from Bi-Mart over the past few days, telling me that they are withdrawing from the pharmacy business, and transferring all of their pharmacy works to Walgreens.

Yes. The folks at the corner of We’re Seriously Overworked and We’re Going To Make A Critical Mistake.

As the title alludes, this is a problem, as it increases the size of an already growing pharmaceutical desert, caused in part by employer health plans funneling through a pharmaceutical benefits manager that mandates the use of a specific pharmacy chain.

As example, I’m only allowed to use either mail order pharmacy, which has its own set of woes I’ve touched on, or Walgreens for any of my maintenance medicines. When I last truly dug in on it, I didn’t own a car: I was dependent on public transportation, either by city bus, taxi or ride hailing, or booking a paratransit trip to and from, which leads to its own set of problems, or cycling to and from the pharmacy when the weather was decent and I felt good enough to handle the trek. Sometimes, a housemate would also be going to the pharmacy, and I could catch a ride with them.

The current pandemic has dug its hooks in deep, changing the overall landscape of everything around us.

Those of us who are trying to follow the plausible rules of distancing, wearing some type of useful face cover that mitigates aerosolization of our own saliva, keeping our hands clean and out of our faces, and staying the f🌕k at home like the book suggests?

It’s becoming harder, as we have to choose between queuing at the local pharmacy with others, or wondering if our damn insulin or testing supplies might make it in today’s mail.

To remove an entire chain of pharmacies during a pandemic smacks of a lack of social responsibility to others, but also feels like it was caused by the continued erosion of a client base by the dumpster fires of pharmaceutical benefit management companies.

It does not help that employers go into their PBM use seemingly blinded by the “Hey, this works, and we’ll save money, right?” approach, missing the blackcurrants for the giant forest fire raging around them.

Let’s talk about the difficulty of getting a blood glucometer on my insurance benefit that I just had to go through:

For once, I am less angry at Express Scripts than I am at Walgreens: the folks I spoke with at E-S were professional, on point, and were very quick to confirm that yes, I can certainly have a finger stick glucometer in addition to my current CGM, because treatment decisions for a low or a high should be meted against blood, not interstitial fluid.

My doctor’s office could and should have asked me which pharmacy to send the glucometer request to (and should’ve listened to the entirety of the data I provided, another story), but they sent it to Walgreens.

I went to pick that up right after work when it was requested and I was notified it was ready.

I parked the car after negotiating garbage tier traffic through a busy segment at 5 pm to get there. As I approach the doors to the Walgreens, there’s a sign on the door indicating that they are only distributing prescriptions through the drive-through, and that the counter to walk up is closed.

I don’t like this one bit, so I get back into the car, and go to drive around to the drive-thru.

A view of the drive-thru at Walgreens.

This is what greeted me, though there was actually one more vehicle here prior to my photo. The queue is poorly designed, forcing me to sit back at a stop sign to allow folks to get out of the drive-thru; there are two other cars not pictured at this juncture on the forward side, and the queue grew by three cars behind me while I waited for this mass to actually not move for ten minutes.

I got frustrated enough that I left, drove over to the sanity-saving FredMeyer because it was about six in the evening, and bought a glucometer out of pocket solely because I really needed one, and I wasn’t willing to spend an hour in line in my car alternating between the clutch and the brake. I just wanted to check my blood sugar, get something to eat, and call it an evening.

Imagine my surprise when I get to FredMeyer, and there’s one person in line at the pharmacy, waiting. Me. Because the only other person getting pharmaceuticals was already being taken care of, and the glucometers are sitting out where any diabetic in need can pick one up.

In appropriate fashion, as I’m being checked out, I thanked the pharmacy tech for being there.

The line at your competition is so long that it would benefit me to buy a glucometer out of pocket so I can check my numbers. I’ve got a wonky sensor and need to check. Thank you for being here and so quick.

– Jayel

They had been hearing the horror stories all day, it seems.

Here’s a food for thought moment as I wrap back to an earlier statement: What if I didn’t have a car and needed to pick up prescriptions? What the hell is that pharmacy doing in those situations? Are they footing the bill for a person to call a cab or hail a rideshare and sit in the drive-thru just to get something they needed to take?

“But Xial, Walgreens delivers prescriptions, too,” I can hear someone arguing in the most nasal of tones.

No, Walgreens does not deliver, if you’re looking for something to be done in a timely manner. I tried to have their home delivery bring me my meds, none of which are controlled substances: they’re my injectables for maintaining my blood glucose. I wasn’t out at time of order — two weeks’ worth on hand, minimum. 10 days after ordering showed no order movement, so the mail order tech basically tells me I should go in to a store for my meds.

It’s all madness and turtles, all the way down.

So, once more, for the crowd in the back:

PBMs cause neighborhood damage by funneling clients away from smaller pharmacies, to large national chains. This often takes away those jobs and livelihoods, containerizing money into the hands of an elite few, who are already buddies with the elite few of the PBM. They sail yachts together.

As the funneling continues, we start to see growth of the pharmaceutical desert, growing to be on par with the already existing food deserts.

I would wonder if someone has done the research to see how much of the pharmaceutical desert affects populations of minorities: how often are their local pharmacies disappearing, forcing them to travel miles and miles away just to get their medicines, or hope they’ll arrive this week in the mail?

That’s food for thought.


On freedom of choice in pharmacies.

I’ll keep this one shorter than usual.

I advocate for the freedom to choose which pharmacy you can go to. Being told you can only use certain pharmacies does not encourage good care.

When a doctor prescribes a medicine for the patient to pick up ASAP, if they are locked into just one pharmacy chain and that pharmacy doesn’t have the medicine in stock, this presents a problem: That patient cannot get their medicine in a timely manner. Mail order doesn’t solve that problem: it exacerbates the hell out of it.

For maintenance medicines, I am only allowed to use mail order or Walgreens pharmacies, at the corner of Overworked and Burnt Out. All other medicines that are basically one-offs, I can still fill elsewhere, like at the local FredMeyer that saved my bacon in 2019 when I had that mail order fiasco in two parts, or the HealthMart pharmacy that I still get my non-maintenance medicines at and am on first name basis with half the staff.

I was prescribed a new medicine on Thursday, and, forgetting that the initial run was NOT a maintenance med, stupidly had it sent to Walgreens.

If this were the easy story, it’d have been sent to FredMeyer, and I’d be taking medicine today.

Nope, Walgreens did not have it in stock at all, and would need to order it. The communication of how long I would have to wait did not happen until I called them the next day and asked if it was ready. No, they’ll have it in stock in about a week, come pick it up on the 8th.

That is not acceptable. That’s nearly as slow as mail order.

Freddy’s will have it in on Monday. Three days faster than that national chain pharmacy, and with a day later start. FredMeyer to the rescue once more.

It’s pharmacy lock-ins that are dangerous for the consumer AND the pharmacists. When one health plan in the area has a lot of patients and mandates only one chain can be used, it dumps a lot of pressure on the shoulders of that pharmacy’s staff, and this means things can be missed, or fall behind, that care that I grew up with at a pharmacy is omitted for the sake of trying to not drown under the weight of concentrated work.

This is another reason that Pharmaceutical Benefit ManglersManagement companies shouldn’t be allowed to continue existing in this way.

Personal Rant

Mail Order Pharmaceuticals, Revisited.

A thought. I gently label it “The American Pharmaceuticals Industry needs a full re-flow. Bake off the bad solder joints, get some fresh stuff in place, and remember the people.” and float on.

Prior to this week, I was relatively tolerant of the idea of a mail order pharmacy, having been forced by Express Scripts to switch, find my way to Walgreens, or only get 30 day supplies of my medicine. This also came with colorful documentation to be like Kyle, who gets all of his prescriptions mailed to his doorstep, doesn’t have to spend time going to the pharmacy, etc.

A preface: I do not hate Walgreens in the context of this discussion. Walgreens, however, isn’t located in a good location with regard to transit in this story. Two buses on different roads run through and turn to head the same direction that I need to go. To get to a stop that allows you to catch either bus without having to find out which bus is coming next (requires: smartphone or a paper copy of both schedules), one must walk a little over a quarter mile to the combined stop. FredMeyer is equidistant with regard to stop access, but has the advantage of not requiring an additional step to get to a grocery store while out grabbing pills. Albertson’s, with their Sav-On Pharmacy, wins for distance with a six hundred foot walk to a combined bus stop — the same one I’d get to on foot if I went to Walgreens, incidentally.

My prior insurance carrier, Providence, allowed me to have 90 day fills at ANY local pharmacy, which I grew quickly fond of after coming off the state’s Medicaid programme — only having to go every 90 days to a pharmacy of my choosing, getting all my scrips synchronized so I don’t have to go frequently and remember to pick up pills, and the like? Who wouldn’t like that kind of convenience, seriously?

Express Scripts would only give me that level of access if I went to Walgreens.

When you think about that, for people who don’t or can’t drive, you bet they’re going to want to line up their travel to be as direct as they can. If I’m going to have to spend a bunch of time waiting on buses, or having to take a Lyft or a taxi, you bet I’d rather have also picked up my groceries while being out to pick up my pills and shots, so I can just go home when I’m done.
If I’m wanting that, I’m sure I’m not alone on it.

So, for the current carrier, to continue getting my quarterly supply of pills, injectables, and nasal sprays, I complied by migrating most of my medicines over. My insulin and my GLP-1 agonist were two of the last three to be migrated, and those were done slowly, one at a time to make sure that things weren’t going to go pear shaped at a bad time. I had extra weeks of each medicine at the time of migration, and wasn’t immediately compelled into this. Everything arrived timely, even though my only incentive was to get medicine in bulk then.

Things were fine, and I was back to a point of spending less personal time going to the pharmacy. I then got my fCGM. Express Scripts was very particular about how I got this filled: I could only pick up ONE sensor at a time, every two weeks.

This irks me for a number of reasons:

  • I’m not even allowed a one month supply of sensors. That is, two sensors at a time.
  • Sensors are attached to the skin with glue. If something pulls it off, I can’t replace it until either the manufacturer sends me a new sensor, or insurance approves an emergency pharmacy refill. Both tasks can take days.
  • I’m not even afforded the courtesy of a backup to remove some of the urgency in case of a sensor removal event.
  • I now have to visit a pharmacy every two weeks, because heck my personal time, it ain’t worth jack to them.

I tolerate this up until Thanksgiving, though — I got that prescription filled a couple days early, because it’s a holiday weekend, and it’s a good thing that I did. I had my first unplanned sensor pull the Saturday after Thanksgiving, with nearly a week left on it. I was able to clean and sanitize the site, and apply a new sensor that I would normally not have had on hand if my local pharmacy hadn’t been awesome and filled ahead of the weekend.

It was at that point that this incident, combined with reading the next year pamphlet for my prescription benefits and seeing the clause about being required to move maintenance prescriptions to mail order or Walgreens, or be denied fills after two courtesy local fills that I decided I’d bite and start the migration after my next local fill to get that process out of the way. It would get me sensors to have on hand, and I could deal with the manufacturer sending me a new sensor kit in the interim is where my thought process took it.

Most of you reading here probably know what happened with that. If not, have a read — it’s illuminating.

Now, I’m sort of laughing at myself after all this, but it’s not for the reasons some of you might think.

Hello again, I’m Xial (pronounced ‘Zeal’, rhymes with ‘eel’). By day, I’m a non-emergency medical transport dispatcher. I help people get to their doctor’s appointments, pharmacies, and the like as part of their health plan benefits on a same day urgency basis. Something that my personal health insurance doesn’t offer, but theirs does.

One of my personal gripes at work had been with folks needing to go to the pharmacy so frequently. I am guilty of grumbling about folks that should be using their mail order pharmacy benefit, because the very line of work I do makes me aware of the cost of transportation.

This week’s events, rather tellingly, changes my tune from “use your mail order benefit” to “Please ask your local pharmacist to synchronize your prescription refills, so you don’t have to go four times a week.

It changes because I’ve learned how horribly inefficient mail order pharmacies can be when they screw up for the populace, and so many people are afraid to give them access to an opportunity to screw them up. I hadn’t encountered the screw-up, and the ineptitude of Express Scripts when handling these problems, so I was very much a blind eye for the darker side of mail order.

People are justifiably afraid of what can happen when mail ordered medicines don’t arrive on time, or arrive in unusable conditions. We’re in the colder part of the year out here in the Pacific Northwest — I’m really not going to want to chance having them mail me insulin and the GLP-1 agonist that I take — neither one of them are rated for being frozen during transport. My refills were staged in such a way that we should be out of the coldest part of the season by the time it’s time for me to refill either medicine.

If I were still in Florida, I would also cringe at the idea of shipping injectables via mail. They’re typically rated for limited temperature bands for excursion. Florida gets very hot to go with its high humidity. It’ll be 97°F (36.1°C) in the sun, with a feels like temperature of 105°F (40.5°C) just standing in the sun as an organic meat computer. Now add a big box truck with poor thermal controls to the equation (which covers USPS, UPS, and FedEx), and you have vehicles hot enough to liquefy chocolate, wilt flowers, and spoil medicines. And this is how these companies want to ship life-sustaining things like insulin‽

All of this just makes me want to force the decision makers at each of these pharmaceutical benefits management companies to eat a four ounce serving of sugar free gummy bears for every validated report of delivery screw-ups. Let these decision makers feel the suffering to the tune of gastric distress every time someone has to start fighting with their damned company because an important medicine is wandering around in the back of a delivery truck half the country away.

Maybe then, they’ll be willing to listen to the rest of us when we say “This is a bad thing. We want choice, and you should pay them fairly.”

… That, or they live with constant diarrhoea.