The Other End of the Stick

To anyone who has worked retail…..

With summer almost over, there’s a lot of catch up on! Here is goes:

This summer I have been interning at Blue Care Network in Southfield, MI. Prior to this I had worked retail and with five years of dealing with rude customers, no lunch breaks and forever long insurance calls - this is a nice break. I started this job knowing only that, calling the help desk at an insurance company resulted in an extremely long phone call that most likely ended with bad news for the patient (who was already mad and hating the pharmacy). But after working at BCN my attitude and frustration towards insurance companies has completely changed!

The first day I started I was given a crash course in Managed Care Pharmacy. I attended a meeting with Medco (they process pharmacy claims for BCN) and was quickly lost in conversation. The acronyms thrown about were insurmountable compared to starting pharmacy school – LOE, COB, DMR, GCN, etc. With managed care, it’s a whole new lingo. For example, patients are no longer “patients” but “members”. In order to keep things straight I carried a notebook with me everywhere to down things I didn’t know (which was basically everything).

Now, for those of you retail interns who are still frustrated with calling and dealing with insurance companies, there is a lot that goes on behind the scenes at an insurance company. Most of you are probably skeptical, as I was, but the goals of BCN are extremely patient focus. The roles of a pharmacist are very clinical in every aspect, trying to achieve the best treatment regimen for all disease states. Almost all of my projects deal directly with assessing clinical guidelines and reviewing literature in order to develop the best treatment algorithms for our members (I can’t remember who taught EBM, but as much as we hated that class, I can’t tell you how useful it really is. I use it every day!) Without-a-doubt there is a “most cost-effective” aspect to managing health insurance, but this is where pharmacists have their role of pushing the clinical aspects.

As an insurance company, managing the formulary is a main focus – things are constantly changing – new drugs are developed, brands change to generic, and clinical guidelines are being updated. One of my first projects was to write an article to physicians on the new criteria for topical NSAIDs. For my article, literature supported that topical NSAIDs should not be used first-line in managing osteoarthritis pain. Branching logic (the different medications that patients must try and fail before given approval to try the drug) was developed and I needed to inform the physicians.

Another project I was given was to research drugs such as Victoza and Provenge. Victoza is for the treatment of Type 2 Diabetes. But due to specific treatment regimen for this drug, BNC created QLs (quantity limits) to ensure it’s prescribed appropriately. These QLs, if exceeded, will stop the claims processing at the pharmacy. It was my job to determine from a therapeutic standpoint the correct QL for Victoza. Provenge, a treatment for metastatic castrate resistance prostate cancer, needed to be evaluated to determine whether or not it should be added to formulary. The cost of this drug is $93,000 per member and it is only 3 infusions. Based on extensive research, I did actually recommend Provenge be added to our formulary. As we speak, documents are now being created to present this drug at the next P&T committee.

There are a number of reasons a prescription rejects at the pharmacy, whether it’s due to step therapy not being meet to exceeding quantity limitations, don’t hate the insurance companies. As you will seen (through me) BCN does a great deal of work in order to provide patient-centered care.