a. The patient pays all prescription drug costs out of pocket, with no insurance.
b. Patients may have a “prescription discount card” that is not an insurance card but provides reduced prices for some medications through a group membership, purchase, etc.
a. Medicaid is federally funded but administered individually by each state. Medicaid bases eligibility on financial need. States determine formulary and copayment amounts, and not all drugs are covered.
b. Medicare is a federally funded program administered by the Centers for Medicare and Medicaid Services for individuals over age 65, disabled patients under age 65, and patients with kidney disease. Medicare Part D provides prescription drug coverage through contracts with PBMs and other prescription insurance providers to coordinate reimbursement.
a. Some drug manufacturers offer assistance programs for patients with special financial needs or those who cannot afford their medications. Patients may present a special prescription card issued by the manufacturer.
b. Drug manufacturers may also offer coupons or vouchers processed as a prescription card that decrease costs for a limited number of fills of a brand-name medication.
a. Compensation for medications used to treat work-related injuries is provided through workers’ compensation. Billing procedures vary, but claims may be billed to the employer directly, through an intermediary, or to the state bureau of workers’ compensation.
IV. Determining Charges and Obtaining Compensation for Services
A. Calculating charges
- Charges for prescriptions and medication orders vary depending on a specific pharmacy department’s policies and third-party reimbursement plans. Chapter 19 provides a review of calculations related to pricing prescriptions.
B. Communicating with third-party payers to determine or verify coverage
- Patients will usually present to an outpatient or community pharmacy with a prescription card. The technician may need to contact third-party payers to verify the patient’s eligibility for coverage. This communication may be done electronically through the pharmacy computer system or by telephone directly to the third-party payer.
C. Obtaining compensation
- Community pharmacy/outpatient setting
a. Reimbursement from third-party payers
(1) For patients covered by third-party plans in the outpatient or community pharmacy setting, technicians will usually submit an electronic claim via the pharmacy computer system to the company providing prescription benefit coverage for the patient. A response is quickly received in the pharmacy computer system detailing whether the product is covered for that patient, what the reimbursement from the third-party payer will be, what the patient’s portion of the cost is, and any other required details.< div class='tao-gold-member'>Only gold members can continue reading. Log In or Register to continue
