The Pharmacy Chick

Flying the coup in retail

An Insurance Tutorial for the customer

Filed under: Uncategorized — pharmacychick at 7:45 pm on Sunday, October 28, 2012

Since its the advent of “open enrollment” season, Pharmacy Chick thought it might be a good time to do a piece to remind our valued customers what insurance is, what it does and good information to consider when you forget to give us your new insurance information  next year, neglect to read the provided mailings and generally plead ignorance when you are quizzed by pharmacy staff when your coverage rejects on January 1.

You think I am being funny…I am not…ok, I am trying to be funny but all of the above WILL happen across the pharmacies nationwide ( as they do every year) on Jan 1.

Previous to the concept of “insurance”, if you were sick, you went to the doctor, and then paid his bill…either by some payment plan or in one lump sum.  If he gave you a prescription, you took it to the pharmacy and bought it. If you had no money, you most likely didn’t go to the doctor because you couldn’t pay for it.  Like other things in life, you could have only those things you could afford to own. I have no doubt that people died from things curable because they couldn’t pay a dr to see them.

Then, somebody came up with this idea of “insurance” which by its basic idea was to take a large group of people to all pitch in a small amount of money…to create a large fund of money to “fund” the illness of those who might get sick over the specified  period of time.  Essentially the “many” fund the “few”.  Its a fair and honorable concept.

Unfortunately it became a veritable monster whose sole purpose it seems has been to sustain itself,using premiums to pay for all the employees of the insurance company ( whose jobs include rejecting claims, avoiding phone calls,  and reducing benefits) instead of paying claims of the members.

Never the less, this massive beaurocratic pig is here to stay so one might as well stay informed.

So for the benefit of my huge readership ( all 7 of you) here are some pretty valuable concepts ( all given to you in laymans terms..right on the table) to help you know about your insurance.  May it prove to be useful.

1. Your insurance counts on your ignorance. Read the materials they send you.  Save those materials, and when they send you new cards, throw away the old ones, and make sure that everybody who provides your health care gets a copy of that new card. Keep all that correspondence in one manilla envelope marked ” 2013 Insurance info”. They are only required to inform you by mail about certain changes, they arent required to make sure you know and understand.

2. New year, new benefits.  Do not assume that what you got in 2012 will be what you get in 2013, and that includes your prescription drugs.  What was covered in 2012 may not be covered at all in 2013, or it may be a higher copay.   Not only what is covered may have changed, but how much you can get can also change…overnight.  You may have enjoyed a 3 month supply of Nexium this year, but next year you may be limited to 30 days…unless you enroll in your mail order option.

3.  New year, new networks.  As reimbursements change, sometimes you will wake up on Jan 1 to find out that your pharmacy ( or doctor or hospital) are no longer in your network, or no longer a preferred provider.

4. New year, new hassles. For every 10 people who wander into my pharmacy on Jan 2 with a prescription to fill and a terminated plan, 8 of them will stammer that “nothing has changed”.  Trust me, it has, and giving me hell because I cannot divine your new insurance will not help the situation much.

5. New year, new deductibles:  So after you have worn off that New Year’s Eve hangover, watched all the bowl games on TV and thrown out the cold smokies and warm soda left on the counter all day, remember this: its a NEW YEAR, and for many of us, including the Pharmacy Chick, the anual deductibles are back on the table.  Because I have a high deductible plan, I am still working on 2012 in late October.  Therefore when your Trilipix goes  10.00 to 148.00 please understand that I am not ripping you off.

6. New year, new card requirements.  This is mainly a hassle for us providers.  Your card might look nearly identical between 2012 and 2013 but often much changes at the provider level.  Sometimes your insurance company changes WHO handles their pharmacy claims.  For us, that is the BIN number…it helps us to find WHO to bill.   If you have medicare D, the beaurocratic pigs in washington make miniscule changes to your cards every year that require we change SOMETHING  every January to make claims submission successful. So you may have had Blue Cross of Gooberville for the last 20 years, but since Blue Cross changed your person code from 01 to 00 in 2013, all of your 2013 claims have to be submitted differently.

Lastly, remember that your insurance is an contractural agreement between YOU and THEM..not YOU and ME.  I have no impact whatsoever on what is covered, what you pay, or how much you can get.  Pharmacies only provide the service.  I have my own contract with the insurance to provide members with drugs that THEY have agreed to pay.  YOU and I have no agreements whatsoever.  Its the same with your physician’s offices.  If something isn’t covered, you have 2 options:  pay or walk.  Dont be surprised if we arent overly sensitive to complaints about price.  We do not set the price and since we pharmacies endure endless complaints in January about price, after a certian amount of time, we simply don’t want to hear about it any more. Don’t take it personally.  If you do not agree with a price or copay, you are not required to purchase the rx, and YOU are always free to call your insurance to obtain more information.  More often than not the pharmacy will NOT have the time to call on your behalf about copay disputes.

So, dear readers, when you get your 2013 packet, pore over it like it was holy scripture.  Review what you are taking now and verify it will be covered next year.  Have a plan. Stay informed and have a plan B in place if the unthinkable happens.

As health care expenses skyrocket, insurance companies look for ways to save money…and they are rarely to YOUR benefit! 🙂






Comment by Jon

October 29, 2012 @ 11:52 am

Thanks for the tutorial. I can’t believe we (yes, all of us using our alleged minds) can’t come up with an efficient and simple system to get the job done without all the b.s. Even if we could, it may not be “allowed” if interested parties didn’t get their “piece of the action.”

Comment by Maggiepies

October 29, 2012 @ 4:22 pm

Too bad you are preaching to the choir. The people that really need this information are too busy annoying the hell of us, asking for a hydrocodone refill 15 days early.

Comment by Pharmacy Jim

October 29, 2012 @ 8:27 pm

I would ask your permission to print this and post it in the pharmacy, but no one would put their cell phone down long enough to read it. Silly, silly pharmacists!

Seriously PC, it’s a great have my permission if you want to post it!! LOL, thanks for the compliment!!

Comment by Mike

October 29, 2012 @ 9:36 pm

Proud to be one of the 7.

As to printing this out, it’s a pretty moot point. Those who know how to read are the ones who already do everything right. It’s just comedy.

Those who need it are still trying to buy soda and toilet paper in the drive-thru.

Comment by Emily

October 29, 2012 @ 10:49 pm

” More often than not the pharmacy will NOT have the time to call on your behalf about copay disputes.”

If only my customers understood this. They want us to do all the leg work for them, and when we even suggest that they contact their insurance themselves, it’s like we’ve just insulted them.

Certainly, we’ll put aside the growing pile of scripts to type and count to sit on hold with the insurance.

Comment by Texas Pharmacy Chica

October 30, 2012 @ 7:04 am


Really, a uniform card format would eliminate millions of dollars in wasted health care expenditures. And if anyone actually bothered reading their booklet, so many things would be clear to them. Not end-to-end, just at least familiarized themselves with it so they could FIND information themselves.

Ha, ha, who am I kidding? People don’t even know how to look up the number for Pizza Hut in a phone book anymore, and I have seriously had patients tell me to call them at work, because they don’t know the number for their OWN cell phone.

Comment by bongos

October 30, 2012 @ 9:11 am

“pore” not “pour”well thank you, I am quite sure it won’t be the last grammatical error found in my work.

Comment by Crazy RxMan

October 30, 2012 @ 9:41 am


Other pharmacists in my company offer to call the insurance in these situations to get correct information when the patient insists nothing has changed. Me, I refuse. It’s not my insurance. I just politely tell them that I don’t have the correct information and they need to get that in order for me to process their claim unless they want to pay cash.

Comment by Elle

October 30, 2012 @ 7:45 pm

Awesome post!

Comment by Mike

October 30, 2012 @ 8:25 pm

Keep in mind that I’m a tech, but my last performance review gave me a low rating in customer service… Despite how well I work with them, know their names, etc. Ever since, I have called every insurance company and every doctors office when the pt has a related problem, no matter how busy we are. I stop what I’m doing to help the patient currently standing in front of me. Drives everyone crazy. Including the 6 people behind them. That’s customer service, right?customer service has a different definition to every company I suppose. I am not sure you are serving the majority when you make the minority your priority. And of course, I have no idea if that is what you are doing or not. I am not going to make a judgement on how you do your job since I dont work with ya!! Did your reviewer define what customer service was? It is mainly ATTITUDE and PRESENTATION? I have a tech who can do some awesome stuff but she does it begrudgingly and it shows. she gets ton of customer complaints about her “SERVICE” and its mainly about her attitude. I do only what I can, and sometimes I make the customer solve his /her own problems and I rarely get complaints..why? because I have a knack of presenting it to the customer in a way that Doesnt’ piss them off….or I ENABLE them to solve their own problems by providing them the map to do so.

Comment by Matthewsrx

November 3, 2012 @ 6:26 pm

I enjoyed the comment about contractual obligations. Very true. I also enable patients to take care of themselves. It is a life skill that many miss. But, I will tell a patient I will cal their doctor for them (called customer service) when I have the opportunity. What I am really telling them is it will be quicker if you (the patient) do it yourself., always proving the roadmap. Have a stamp or sticker made with the insurance co. Telephone number. Regarding prior approvals I explain that their doctor must call their insurance company. Period. And that the price is set by their insurance co. And the copay is what their insurance asked me to charg you.

Comment by JS

November 4, 2012 @ 1:36 pm

And then there are people like me:

My insurance is based on a fiscal year (7/1-6/30) I pay a reasonable, yes I said, reasonable amount until $1500 comes out of my pocket; then my co pay goes to $0 through 6/30. I usually make that $1500 by 12/31/12 (it often depends on how many times I am hospitalized and for how long). When I pick up four scripts and my total is $200 I don’t freak, gasp, yell or scream. I thank G-d that I don’t have to pay what they would normally cost. For example, I take 4-8mg of Odansatron QID (this is NOT a PRN drug for me). Pharmacy “Peeps” I am sure you can do the math in your head. I get 900 mls. per month. For those not in the field, it’s just under $3000 cash. People behind my gasp and comment and I simply turn around and say, “It’s better than paying cash, and would you please step behind the privacy line!”

I always read my insurance info (RX and MD) however, about two years I realized I must be doing something wrong. Periodically (remember my insurance is based on a fiscal not a calendar year), I would get checks from my doctors in $15 increments. I didn’t think much of it, figured my doctors just liked me and were thanking me for having chronic health issues, referring others, and well, just because I am nice (LOL)! That wasn’t it. I have a $15 co pay (sort of) that vanishes after I make my annual $1200 deductible. The first $500 is mine, 100%, then I go to 80/20 until I pay another $700. Keeping in mind my insurance dates, I make this no later than 7/31. One year I made it on 7/1. So, I was getting that money back because I had made my entire deductible and was still making ALL my co pays and they kept taking them even though there weren’t supposed to. Oh well! It was a nice surprise. I stopped doing that, since it probably makes their “money person’s job” a PITA!

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