The Pharmacy Chick

Flying the coup in retail

Insurance 101 ( a January refresher)

Filed under: Uncategorized — pharmacychick at 7:49 pm on Monday, January 15, 2018

Now that we have launched into a new year, it seems appropriate to offer up a quick course offering in what can only be called “Insurance 101″ for patients . I really should be doing this every year…copy and paste…for my own customers because over the course of a year many seem to suffer from selective amnesia each and every January…

So lets launch into the basics of Insurance:
1. Its a contract between YOU the patient and your insurer. Either you are paying the premiums or your employer is ( or a combination of both) The insurance company takes your money and in exchange agrees ( in theory) agrees to pay claims for health care. Please note they are in the business of paying as few as possible and keeping as much of YOUR premiums in THEIR pockets. They in NO WAY actually care about your health no matter what their ads may say. Don’t let their propaganda sway you. They are a for-profit entity and they definitely like their profits. The only reason they want you healthy is so they make more profits.

2. Your pharmacy has a contract to accept claims. Imagine a naked man over a barrel. We are that naked man. You also are a naked man over a different barrel. We are both naked. The insurance company has all the clothes….and they own the barrel. Pretend there is a guy with a whip over that naked man. THAT is the insurance company.

3. The pharmacy does 2 things with your insurance and thats all: we fill a prescription under their guidelines and we collect the copay. we do not:
a. set the copay ( they do)
b. decide what is covered( they do)
c.have any say in how many is covered ( they do)
d.choose how often you can pick up the prescription. ( they do)
Do you see a trend here? ( I do)

4. These are the wrong things to say to your pharmacist
a. ” that price is wrong”probably not, in fact, if I have a properly submitted claim, its definitely not but if you can convince your insurer to change the price, you have my blessing and support

b. ” thats not what I paid last time”  might be true…but completely irrelevant. especially if its in a previous year

c. ” can you call….” stop right there…no, I don’t call insurances to discuss price because I am not involved in that, nor will I call a doctor to change a prescription because you don’t like the price.  I will however FAX the price or rejection information to the DR and let him decide how to proceed. Your therapy is between you and your physician.  I don’t have access to preferred formularies unless its transmitted to me and 99% of the time its not and its not generally appropriate or appreciated for me to approach the doctor about changing treatments .

d. ” Its your fault if I die”.  nope its not, and it will never be unless I have made a grievous error in the prescription.  If you refuse to take a prescription because of price, or refuse to follow up with your physician because something isn’t covered that isn’t my fault or my problem.

5. The insurance company would prefer you to have substandard care…FALSE  They expect you to have a high standard of care but that doesn’t mean that they have to pay for the most expensive drugs on the market.  There seems to be a common misconception among people  that when Expensivicon 100mg comes out  that all of a sudden that Cheapolol  is substandard and ineffective.  That is highly incorrect.  For the most part, the recent trends in “new” drugs is to retool an old one to simply keep a patent a little longer, without providing  any great therapeutic  advance or benefit.  Believe it or not Cheapolol has kept people alive for many years and will continue to do so despite the presence of Expensivicon !

6. Prior authorizations are becoming more common place so its probably a good idea to familiarize yourself with that terminology. This happens when a drug is not covered but MAY be if  certain criteria are met.  If its not met, then the answer is NO, but if it is, it may be covered.  Usually if its granted it will be at your highest copay level so be prepared for that. We don’t get them, the DR asks for them and they can take a few days to a few weeks depending on who takes ownership of the process. We sent a notice to the Dr’s office once and then they have to do the rest.

7. Cards…those plastic things they give you?  Carry them and show them to me EVEN if they look the same as last year…. Really..because something as small as a BIN  or PCN change will make you ineligible for coverage and while those TLA’s mean nothing to you, they mean everything to me.

8.  There is a big difference between December 31 and Jan 1.   It may be only a few hours, but its an entirely different benefit year and its a whole new game. Im sorry if you ordered a refill on December 31 and the Doc didnt authorize it until Jan 2.  When you asked for it may have no bearing on when its actually filled when its out of refills.

9. Read everything they send you! Dont just rip open the mail, extract the card and pitch the rest.

I know this doesnt cover all the nuances of the insurance mess that pharmacies deal with every day but this is a good start.  So, to distill it down to the basics….   1.  New year, new deductibles.2. Keep your card close and show it to us.  3.  Read the materials they send you. 4. Pharmacies dont write the rules.  5 Benefits change.


Cheers! Pharmacy Chick





Comment by Alex Cline

January 16, 2018 @ 2:24 pm

YES!!!!!! All of this!! Going to print this to hand out to ALL my patients

Comment by Donald Black

January 17, 2018 @ 2:28 pm

Yes, especially #5. I am a pharmacy technician that handles the ordering at a free clinic. We get ‘Expensivicon’ when we can (i.e. for free), and some doctors (who are volunteers) are disappointed when we don’t have their special pet. i have started thinking how the human race has somehow survived thousands of years without ‘Expensivicon’ and will probably continue with or without it.

Comment by Karen, RPh PharmD

January 18, 2018 @ 9:30 pm

SPOT ON!!! Please come work for me – we don’t have warm winter but we have snow and ski hills and right now you can golf on a green course!

Great job speaking what is in my head!

You are loved. Hugs

Comment by Margaret, RPh

January 22, 2018 @ 7:06 pm

Every year I tell myself that I should take my vacation in January and July when the insurance plans change. Every year I forget. Accepting third-party payment is the biggest mistake the pharmacy profession has made! We should charge cash and let the customer send the bill to the insurance for reimbursement. Too late for that now, sad to say!

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