1. Insurance
Henderson

2. Third Party vs First Party
An organization that processes insurance claims. Example: Insurance companies
First Party:
In-house accounts some pharmacies set up for their patients so they can pay once a month or however arrangements are made.

3. Types of Reimbursement
Direct Third Party Payment:
Pharmacies submit claim forms electronically to a third party payer for pharmacy services. Pharmacy is then paid directly from the third party entity.
Out of Pocket Payment:
Patients are initially required to pay for the pharmacy service but can submit their receipt along with insurance forms for reimbursement.

4. Provider Pharmacies
Some agencies have a partnership with pharmacies to offer better pricing for increased business.
Typically, there is some sort of contract in place to protect both the pharmacy and the provider.
Examples:
St. Marks Food Bank
Intermountain Hospital
Some out-of-state hospice programs
Vocational Rehabilitation

5. Claim Processing
Pharmacy Benefit Manager (PBM): Companies that only handle prescription billing. **The BIN number on the pharmacy insurance card indicates which PBM you are sending the claim to.
Electronic Adjudication:
Most popular method of submitting pharmacy transactions.
Quick
Efficient
Safe
Universal Claim Form (UCF): This is a paper claim.
Doesn’t guarantee payment
Only usually used for special circumstances

6. Other Third Party Considerations
Coordination of Benefits (COB):
The process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for patients who have more than one coverage.
Formulary
A document or listing of committee- approved drugs in stock. This is the function of the P&T Committee
The main goal of a formulary system is to manage the cost of drug therapy.
Remember the DAW Codes
0- Substitution allowed
1- Doctor requests Brand
2- Patient Requests Brand

7. And more… Quantity Restrictions: Prior Authorizations: Signature Log
Third Party Plans may limit the qty of medication that can be dispensed.
Is this good or bad for pharmacy business?
Prior Authorizations:
Some drugs require special approval before the third party plan will pay
Signature Log
During a pharmacy audit by a Third Party Payer, they will often request a signature of the patient for the drug on the date it was sold as proof the patient got the prescription.

8. Terminology
Copay: What the patients is supposed to pay if/after the claim is submitted to insurance.
Deductible: The amount the patients has to pay before insurance kicks in.
Donut Hole: a “gap-in-coverage” where the patient has to pay the majority of amount until the “gap” has been fulfilled. (usually around $2500)
Premium: The amount a patient has to pay to have insurance.

9. Types of insurance
Medicare
Medicaid
Commercial
Tricare
Coupons

10. Medicare Part B Offered to patients 65 years or older.
Covers DME (Durable Medical Equipment)
Canes, walker, nebulizer machines, dressings, oxygen,
******DIABETIC SUPPLIES, NEBULIZER SOLUTIONS, TRANSPLANT MEDICATION
Offered to patients 65 years or older.

11. Medicare Part d Covers prescription medication
Offered to patients 65 years or older
These have a deductible and a donut hole.
Examples:
True-blue
Humana
Caremark
You can go to Medicare.gov and enter in prescriptions to find the best Medicare plan for you patients.

12. Medicaid Qualifications include: Plan offers: Zero Copays
Children ages 0-5 qualify with family income up to 142 percent of the federal poverty level (FPL)
Children ages 6-18 qualify with family income up to 133 percent of the FPL
Pregnant women qualify with family income up to 133 percent of the FPL
Parents with dependents qualify with family income up to 24 percent of FPL
Children qualify for CHIP (Children’s Health Insurance Program) with family income up to 185 percent of the FPL.
Plan offers:
Zero Copays
Plan limitations:
No “early refill” overrides
Cannot fill out of state

13. Tricare Insurance for military and families.
Prescriptions are FREE if filled on base (here, the closest is Mountain Home)
If filled at another pharmacy, most generics are $9 and brand are $21. BUT there are exceptions and the copays are subject to change.

14. Commercial Insurance Obtained through employment.
Usually have high premiums.
Examples:
Blue Cross
Medco
United Healthcare
Express Scripts

15. Coupons These are entered as if they were an insurance plan.
Can be for specific products (usually brand name and expensive):
Cialis, vagifem, eliquis, xarelto, Advair, lantus, etc
Misleading

16. Coupons continued Can be a savings card for any prescription:
IdahoRX
GoodRX
**These are not ideal because typically the pharmacy loses money on these pretty regularly
These are delivered to doors, mailed, on phone apps…..everywhere!!!!!!!

17. Numbers on a Pharmacy Card
BIN number (6 digits)
PCN number
GROUP number
ID number
**If the ID number has letters in the beginning, usually leave them off.

18. Insurance Rejections REFILL TOO SOON NDC NOT COVERED ON PLAN
Usually, insurance will tell you in the rejection when the earliest date is you can fill it. Solution: Resubmit the claim at a later date
NDC NOT COVERED ON PLAN
Insurance will not pay for this drug.
Solution: Patient can either pay for it out of pocket (without insurance) or you can try to call the doctor to change it to something else.

19. Insurance continued: PRIOR AUTHORIZATION DAY SUPPLY NOT ALLOWED
Insurance doesn’t want to pay for this drug (usually because it is really expensive and there are cheaper alternatives)
Solution: Patient can either pay for it out of pocket (without insurance) or you can alert the doctor and THE DOCTOR needs to contact the insurance and complete the prior authorization.
DAY SUPPLY NOT ALLOWED
You are probably trying to run greater than a 30 day supply.
Solution: resubmit with a 30 day supply.

20. Insurance continued: ID NUMBER INVALID:
Patient may have gotten new coverage.
Solution: Request a copy of the patients card to verify info. If you see no errors, call insurance to verify eligibility.