From the Mind of Trevor Stone

Your Org Chart Is Showing, and other reasons CVS is "special"

Tue, 01 Oct 2024 05:18:15 GMT

My employer-sponsored health plan has a "specialty pharmacy" insurance which is separate from the ordinary pharmacy benefits. Painkillers for surgery post-op, antibiotics when you're sick, prescription NSAIDs for chronic inflammatory disease, and all those other medicines that come in an orange plastic container are reliably dispensed by my local King Soopers pharmacy with what I would describe as a high level of competency. Other than "we haven't filled it yet, can you come back in an hour" I haven't had any problems acquiring or paying for any of these medications for fifteen years.

The "biologic" disease-modifying drug I take for psoriatic arthritis, on the other hand, is considered a "specialty medication" which means it's paid for by CVS Specialty Insurance, filled and delivered by CVS Specialty Pharmacy, and picked up at my local CVS Pharmacy. Despite all having the word "CVS" in the name, as far as I can tell they're three separate entities who are almost incapable of coordinating with each other.

Drug manufacturers have learned that they can charge a lot of money for biologics. But if they charge too much money, patients with a 10% copay will balk at the price, avoid filling the prescription, and the drug company will miss out on the other 90% that would've been paid by insurance. So they came up with a way to hack the U.S. health payment system: offer patients a "co-pay assistance" card, which is basically a persistent coupon lowering your out-of-pocket costs to almost nothing. Patients will then keep filling the prescription because it's basically free, leading to something of a principal–agent problem where the person making buying decisions has no incentive to consider the cost of the item. My employer ends up footing the bill, but I'm only annoyed with this situation in principle: in practice I get free drugs. (My employer benefits too, because I was not very productive when my symptoms were causing problems and I wasn't taking the drugs.)

In late January or so of this year, I received notification that starting April 1st, our CVS Specialty Insurance plan would no longer cover Humira—the name-brand adalimumab—and would instead be covering Hyrimoz, a cheaper generic adalimumab. This seemed like a bit of an unfair move, since employees can only change decisions about health care plans near the end of the year, but as a fan of generic medicines this seems like a sensible choice. However, although this change was announced in January so people could start worrying about it, we couldn't actually take any action like getting a doctor to change prescriptions for more than a month. Come mid-March I called CVS Specialty Pharmacy to fill my new Hyrimoz prescription, but was told that since CVS Specialty Insurance didn't cover it until April 1st I couldn't actually place an order until April (including "place an order in March for April delivery"). This was rather inconvenient, since I was leaving town for two weeks starting April 1st and didn't want to spent my road trip vacation arguing with pharmacy customer service people when things would eventually go awry. The customer service rep did inform me that I could set up the co-pay assistance card in advance, though. After several attempts to use the drug manufacturer's website that had some technical hot mess I can't recall, I finally got a PDF that had two sets of discount code numbers on it, one "for NDC starting with 61314" and one "for NDC starting with 83457." As a health insurance policy holder I still have no idea what NDC stands for, nor how I would figure out which of those two apply to me. I relayed this to the person at CVS Specialty Pharmacy who suggested she take down both sets of numbers and put them both in their system so they could figure it out once the prescription actually gets filled.

Come April I was able to order a 3-month supply of Hyrimoz, plus a bag of alcohol wipes and a sharps container. I was somewhat surprised that the medication was delivered without much issue, given my prior experience of organizational incompetence ordering Humira. When I tried to pick everything up, though, the retail CVS Pharmacy folks were getting some indication in their system that they shouldn't hand over the sharps container and alcohol swabs, so I walked away with a couple thousand dollars of medicine and not ten dollars worth of common medical supplies ¯\_(ツ)_/¯ (It only took a day or two for them to realize I could take a sharps container to dispose of the future medical waste they handed me the previous day.)

A few weeks later, someone from CVS Specialty Pharmacy billing department called and informed me that I still hadn't paid my copay for that order. I was surprised, since I'd given them all the information on the card which claimed my copay would be zero dollars. I think we discovered that there wasn't a card on file, so I gave both sets of numbers again and the rep said she would rebill. Problem solved? Hardly. I don't recall the exact timeline, but when I attempted to refill the prescription in the early summer I discovered it was on hold because the prior order hadn't been paid. So I called CVS Specialty Pharmacy; we went through the numbers again, and she determined that based on the diagnostic code from CVS Specialty Insurance the code for the wrong NDC was in their system and she didn't have the other code, so I re-provided all the digits. After some time on hold she confirmed the order had been rebilled.

So imagine my surprise this weekend when I was sorting through an accumulated pile of mail and discovered that the charge from April had been sent to collections. I called CVS Specialty Pharmacy this morning, and pointed out they had a discount card on file. The representative said they would rescind the bill from collections and rebill insurance. Will CVS manage to pay itself this time? Who knows! The two companies seem to share the same name but otherwise lack the ability to communicate effectively.

Payment aside, order fulfillment and delivery is also a comedy of errors. In early September I received a text message from CVS Specialty Pharmacy that said my prescription was ready to be refilled, but when I went to CVS Specialty Pharmacy's website it said I couldn't refill for another week and a half, and once that time passed I could only schedule delivery for another week and a half later. When I arrived at the retail CVS Pharmacy I was handed a large paper bag that was wet and soggy on the bottom. This contained a cold bag with three ice packs and a single box of medicine, 90 alcohol swabs, and three sharps containers. It's unclear to me whether the Specialty side (which distributes this temperature-controlled medication from a warehouse somewhere) or the retail side (which keeps medicine in the refrigerator until I pick it up) were the ones who decided to keep sharps containers and alcohol swabs should be kept refrigerated, but I'm quite glad I didn't pick this one up on a bicycle commute day because that bag was a wet mess. More importantly, I was rather miffed at CVS Specialty for taking my "Please send me three months worth of medicine, alcohol swabs, and a sharps container" into one month of medicine, a year's worth of sharps disposal, and three years worth of swabs. The order sheet says "2 ml" of Hyrimoz, and each box contains two 0.4 ml pens, so it would take two and a half boxes to match two milliliters of medicine; I only got 0.8. I attempted to call CVS Pharmacy retail about this problem, but every attempt to use their phone tree's "Leave a voicemail and we will call you back" feature resulted in the computer voice saying they were sorry. So I stopped by the pharmacy in person to tell them (1) file a ticket to get your phone system fixed and (2) you didn't give me my whole order. The pharmacist explained that they could view and dispense CVS Specialty Pharmacy orders but couldn't do anything else like investigate why it was wrong, so she gave me the phone number for Specialty. You guys are both CVS Pharmacies, why can't your computers talk to each other? Another call to the other CVS turned up the fact that two prescriptions, one for a one-month supply and one for a three-month supply, were both in the computer system, and the system automatically selected the first and billed insurance for it. She said she put a note on my record to do the three-month supply next time, and assured me that I would be able to place that order in October. I've a rather sneaking suspicion that they'll manage to fumble something again and I'll have to take another adventure through their customer support lines to convince their computer that I'm eligible for more drugs before December. (I discovered my previous order sheet this evening which says it was filled for 6 ml, which would be a 10 week supply rather than a 6 week supply. I guess I shouldn't be surprised that CVS Specialty can't even get arithmetic right.)

I wonder if it's occurred to the folks who run my company's benefit plan that I'm not doing anything productive for the company if I spend half a day getting derailed by systematic incompetency every few months.

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Core Oh No Virus

Sat, 14 May 2022 07:05:40 GMT

The past couple months have felt like things were getting back to normal. In March(?) we got to have assigned desks again at work, which meant I could do things like stand on a stress mat, not bike with a laptop every day, leave a box of Altoids on my desk, and see what Chrome tabs I had open on March 11th, 2020. In early April I took a road trip, then met our Canadian coworker in person for a week of team bonding. I'd been reminded that Happy Thursday is a thing I used to do, and made it to three weeks in a row of colorful people riding colorful bikes around town. Eating food in restaurants feels normal. After a chilly spring season, I'm summer season captain for the office softball team, which has been playing pretty well.

On Sunday I climbed around on ladders and garage roofs to help a blind friend get his ham radio antenna re-attached after the big wind storms this winter. I then took my parents out for Mothers' Day dinner. After I got home from dinner I noticed a bit of a scratchy throat, so I took some vitamin C and went to bed at a reasonable hour. I'd been feeling more sore and tired than usual during the previous week, including discomfort lying in bed and being really tired when waking up. This feeling was reminiscent of my state a few years ago before I started taking Humira to tamp down my immune system, so I wondered if the drug wasn't working as well as it used to, or if I'd ended up with a weaker batch. I also reflected that I'd had lots of late nights sitting in a somewhat awkward chair being engrossed in the Internet, so self-induced posture problems were a possible cause.

On Monday I was extra sore and tired when I woke up at about 10:30, so I decided to work (and slack off a bit) at home, given the scratchy throat. I took a fancy Cue home COVID test in the afternoon, which was negative. I worked on some code on the back porch, and finally took the initiative to call the power company about an every-10-second beep that had been annoying for months. I used the last of the light to attempt to get the sprinkler system running again, but didn't have quite the right setup. My arms, particularly the right one, were still sore (I chalked it up to lots of computer mouse use) and my pelvis felt out of shape, but overall not terrible. I took a long bath; it took all my energy to get up and out of the water, but that's usually how I feel when I'm drained enough to need a hot bath. On Tuesday I woke up around 11 with a similar lack of satisfying sleep and lots of sore body parts, so I decided to take another light day from home, including taking part of the afternoon to get the sprinklers working right. Our softball team didn't have any subs available, and I felt good enough to pitch the whole game while wearing a mask. (The tricky bit was positioning my sunglasses so they wouldn't fog up from the mask, but still keep the setting sun at bay.) Wednesday was another day of waking up sore and tired. It took me several hours to get through a bowl of granola, but that sometimes happens if I end up pouring more in, or I hit a patch with a lot of finely-crushed bits. I did some more work-from-porch relaxing and decided that a walk might help me feel better, so I got dressed and headed over to a meeting where we were testing out technology and room arrangement for a hybrid meeting setup. I was wearing a cloth mask, the other participants were wearing N95s, and we were about 10 feet apart. Going in I'd felt pretty confident that I didn't have COVID (see: test from two days before), wasn't contagious (very little coughing), and was probably having an immune overreaction to something. I started questioning the decision during the meeting, though, as I started having some very shallow coughs and was feeling a mild fever. Later on Wednesday night I felt extra drained, requiring a significant fraction of my spoons to empty and load the dishwasher, which I hadn't mustered the energy for in several evenings.

Thursday was the worst day. The week of ache had compounded, I was frustrated that lying in bed hurt and therefore wasn't restful, and I was exhausted. This was clearly not a "short overreaction to a minor virus" experience. I still didn't have much appetite, was coughing more (still shallow), and had approximately no energy. Kelly thought she saw some concerning signs in my mouth, and encouraged me to see a doctor. In 2022 if you feel sick you're not supposed to go physically to the doctor, so I had a telehealth adventure: sticking my tongue out close to the webcam, trying to shine a small ring light on just the right tongue spot, using a butter knife to sample mucus, and grabbing a home thermometer for a quick test. No stethoscope was simulated, and I didn't record my own height and weight to completely virtualize an office visit, though. The doctor hypothesized a bunch of possible illnesses from flu to COVID to strep throat. They had me do a drive-through test at the hospital. COVID testing has progressed to the point that there's now a combined respiratory test where a single nasal swab will produce test results for COVID, influenza, bronchitis, and about a dozen other respiratory illnesses. The strep test gets swabbed in a different hole, but also gets cultured for a whole raft of possibilities.

Late in the evening my email told me to check my medical portal, where I learned I'd tested positive for coronavirus. D'oh. I quickly emailed the folks I'd met with on Wednesday with profuse apologies and warnings. I emailed next week's planned house guests and recommended that they seek other accommodation. I texted my radio friend a warning. I called my parents. I emailed my softball team and texted the other team's captain. I emailed the coworkers who sit near me. I filled out a "Report Covid" form at work which had a bunch of questions like "What are your symptoms" and "Have you been in close contact with someone who has tested positive" which should be unnecessary if I could start the form with "I tested positive for COVID, tell anyone who badged in to my floor about it." Wow is it a lot of work to do your own contract tracing, it's a good thing I didn't have the "can barely get out of bed" flavor of COVID.

While pursuing responsible disclosure, I opened the Colorado Exposure Notifications app on my phone to figure out how to report a positive test there. I was greeted with a big button asking me if I wanted to enable exposure notifications, and that doing so would require Bluetooth. "Um, yes, please, what in the world have you been doing this whole time?" was roughly my reaction. I'm pretty sure I installed this app in 2020, turned it on, and assumed it would quietly do its thing. I took not having received an exposure notification so far as a sign that my mostly-isolated life over the last two years had meant no close contacts with anyone who tested positive. I hadn't considered the alternative theory that the app had quietly turned itself off (maybe when the phone was in Airplane mode, or after an OS upgrade?) who knows how long ago. I don't recall seeing any "Exposure notifications are turned off" system notifications. This felt like a smoke alarm which doesn't beep when the batteries run low. YOU HAD ONE JOB! I also did another Cue home test, which came back positive. It's encouraging that it detects it (the virus hasn't evolved to evade detection), and an important data point that it might take a couple days of feeling lousy before the test is accurate.

On Friday I woke up to a call from a medical assistant at my doctor's office who said the doctor could send a prescription for Paxlovid, an antiviral medication for COVID. (I haven't been closely following the coronavirus news for awhile, so I was unaware that such a treatment was now available.) They said they could send it to CVS Pharmacy inside Target, an establishment I'm familiar because, for reasons of opaque employer insurance pricing, is where I get my "specialty" medication, even though all the rest of my prescriptions go through the pharmacy at my local King Soopers. I've speculated that this arrangement might be because it was such a pain in the ass to get the prescription set up with CVS Speciality that maybe someone saves money from people giving up and not ordering their specialty drugs. I called their phone system in the early afternoon, giving "Prescription status" to the automated voice system. It asked me for the prescription number which of course I didn't have because I am calling to find out whether you received the prescription. When I convinced the AI that I didn't know the prescription number, it attempted to transfer me to the pharmacy, which was closed for lunch. After lunch I called back twice; the first time "Prescription status" got interpreted as "Covid masks" and without asking for confirmation started to explain that the store sold those. I hung up and tried again, this time "Check prescription status" somehow became "Covid vaccinations" and it transferred me to a recording about how to schedule a vaccination. I called my doctor's office instead, which at least has a recording of a human reading numbers you can press. I reached someone who said they only saw the King Soopers entry in my records as a pharmacy. I explained that I didn't care what pharmacy filled this prescription, I just wanted to know if it had been sent and where it had gone. They called me back shortly and said it was sent to CVS. I called CVS back and hoped that pressing 0 would put me in the queue for talking to a human being physically present in the same place as my drugs. After 15 minutes on the same automated message cycle, including a point when the recording drops out for a few seconds, giving you false hope that someone's actually answering the phone, I asked if any of my teammates were at work this afternoon and could they do me a favor. I armed my manager with my date of birth and got him to walk next door to the pharmacy in Target and check if they'd received the prescription. After a couple minutes of confusion they realized that for a freshly-received prescription they needed to check a different computer system, where it had in fact been received. My manager told me it would be filled in about 25 minutes. I was still in hold message limbo, 50 minutes after starting the call. Not sure what I would've done if I didn't have allies within walking distance of the pharmacy. The "You're not allowed to pick up your medication yourself" challenge builds on the "When you're sick you shouldn't go to the doctor's office" wrinkle from the 2020s expansion pack.

Ironically, after spending all afternoon trying to make sure I could get my hands on Paxlovid before the pharmacy closed and the "Start taking within 5 days of symptoms" window expired I was actually feeling fairly good, way better than Thursday when I'd made the doctor's appointment. (Hail to the vaccines that gave my immune system practice last year.) Another coworker dropped off the medication, my dad brought over a grocery delivery of coconut water, soup, ginger beer, orange juice, and grapefruit (you can tell we're in a mindset). I'm celebrating the fact that I haven't lost any sense of taste by eating kim chi and chocolate fudge brownie ice cream. Kelly and I live in a house where we can easily avoid direct contact, each getting a bedroom, living room, and bathroom to ourselves. All in all, things could be a lot worse.

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