Friday, January 8, 2010

Plan Limitations Exceeded

How many times a day does that message pop-up on your third-party rejections screen? Usually it happens when you are trying to submit a claim for a 90 day supply when the plan only pays for thirty. Or when the prescribed dose takes the medication over the plan's daily limit, which is sometimes resolved with a quick call to get the override.

Other times it pops up when a maintenance medication is trying to be filled at the local retail pharmacy and the patient's plan requires mail-order after the first two fills at the local pharmacy. I get that. I expect that..... in March or April.

Not on January 2.

I had that message appear on one of the first prescriptions that I filled last Saturday. And since then about two scripts per day. A little bit ridiculous.

Oh wait, I forgot to tell you what the secondary message said:

-Please have customer call CVS Caremark 888-769-9030

Now you know what's going on. Even though my pharmacy is contracted with CVS Caremark, I'm only allowed to fill one prescription for my patients, then I have to tell them that they need to either go to the CVS that is two miles away or start mail-ordering. Somehow this doesn't seem right to me.

But stuff like this has been going on for years. And it's not exclusively CVS Caremark.

This is what happens when insurers of prescription medications are permitted to be providers. They set up little rules that force the patients to use them. Want to use a non-preferred pharmacy? No problem... copay will be doubled... if they allow you to use the non-preferred provider.

A year or so ago I called an insurance company to see how I was being reimbursed for a particular medication that I felt our pharmacy was being low-balled on. I wanted to know which formula was being used.

Federal MAC-plus?




I think it was the insurance company's MAC-plus list, because I couldn't get the math to work out using any of the other formulas that were included in our contract. I asked for a copy of the insurer's MAC-plus list to be emailed to me.


Proprietary information.

So here's where we are. Insurance company (who is also a provider) gets to pick and choose which reimbursement levels the contracted pharmacies receive. They won't let us see the list of medications that are on each list. We just have to trust them.

I wonder if the reimbursements are also based on NCPDP numbers. Maybe the locations that are affiliated with the insurer get a little bit higher reimbursement levels. Competitors get a little bit lower levels. Hmmm.... I wonder how the insurance company's profits are doing?

Just some things to think about.

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This is not an indictment of CVS Caremark. They are the national-level player that everybody can identify with. I personally think these practices occur more frequently at insurance companies that operate on a local/regional level where they hold a significant market share.


Anonymous said...

I know that this is not just this insurer's's every ding-dong insurer's policy.

The psychiatrist called me to find out how much the big guns cost, Geodon or Seroquel or something else for the nearly indigent patient, so we could work out something that would be effective for the patient and less cost to the government agency picking up the tab. He gave everything about the patient. I called the insurance company. First, the tech that answered said they she couldn't give the information,
'But, but' I said, 'I am acting in good faith for the benefit of the patient, how am I supposed to be able to compare costs for the prescription if I don't know what will be charged?' "No." 'Fine, please, transfer me to the pharmacist.' Dial tone. 30-40 mins. re-try. Again, no luck. The insurance company is rampantly running the whole business into the ground. THAT IS WHY I was rather 'upset' that WE COULD NOT EVEN get a PUBLIC OPTION, wherein, the ordinary pharmacist, someone in charge of medication therapies working in the best interest of the patient would be able to find out COSTS of drugs. Yikes.

Mark said...

I'd guess that a public option would still have used PBMs like the Medicare Part D program, so there still isn't a guarantee costs would be readily available.

And as pointed out above, COSTS aren't all that relevant when the compensation to different pharmacies is variable by their contracts with the insurers.