No Good Deed Goes Unpunished

We all know that that Friday afternoons are hectic in the community pharmacy, especially the first of the month. One Friday, after finishing my typical lunch (yes, I take 10 minutes to do that), I called a pharmacy for a transfer for one of our patients. As I was on the phone, I overheard my technicians, Amber and Katie, looking for trifluridine eye drops. I reminded them to check the refrigerator. None there. After I was done with my call, I asked who wanted the trifluridine drops, assuming it was another Thompson Pharmacy. They said it was some eye doctor’s office but could not recall which.

About 7 years ago, my niece Rachel Fritz, who is now an optometrist, stayed at our home while interning at a local eye clinic. I came home after work one day and told her that a Medicaid managed care organization (MCO) denied a claim for trifluridine because the patient used their 6 prescriptions for that month. I called the ophthalmologist and got the medication changed to valacyclovir, knowing Medicaid would pay to treat genital herpes but not herpes keratitis.

“Uncle Pete, herpes keratitis is sight threatening, and you probably saved that patient’s vision,” Rachel said. Herpes keratitis needs to be treated within hours of diagnosis, and waiting 2 days for prior authorization is not appropriate. My techs called all the ophthalmology practices in Altoona, Pennsylvania, and tracked down the nurse who made the request.

I spoke with her, and she said no one in the city had the eye drops in stock. I told the nurse to give me the prescription over the phone and my driver would go to the warehouse to pick up this sight-saving eye drop. I called “Rich,” the representative at Value Drug, around 1:15 PM, and he set the wheels in motion. Less than 2 hours later, my driver, Don, appeared, drops in hand.

When the patient’s daughter came in at that day, she was most appreciative of our efforts. Her 90-year-old mother was a customer of a big-box store, where little effort was made to help this patient. The woman handed me her mother’s Medicare Part D card, and Amber ran the prescription through our pharmacy filling software. When Amber got the approval, her bright smile was absent from her face as she called me over.

Amber informed me that Medicare Part D had paid us $123.02 for this sight-saving eye drop that cost us $189.93, for a loss of $66.91. That’s not counting all the time my techs spent, the mileage and time my driver spent, and time I invested to help this 90-year-old woman get the medication because the big box had no interest in doing so. What should we do? I assured Amber that over the weekend, I would fill out the paperwork to challenge this gross injustice of payment.

My only wish is that the pharmacy team at this MCO could hear my niece say that herpes keratitis is sight threatening and needs to be treated immediately. There was no time to scour other warehouses to find a cheaper generic. This small, 1200-square-foot drugstore will take care of the patients and their problems that the big-box guys could care less about.

Clare Boothe Luce is attributed with saying “No good deed goes unpunished.” This independent pharmacist hopes that this is not the case for the herculean efforts made to help this most needy patient.