Your pharmacist and his staff screen a new prescription for errors, then enter the data into the computer. If a problem is noted the pharmacist will contact your physician. The prescription is dispensed to you and a face-to-face counseling session informs you how to take the medicine correctly, what possible side effects or adverse effects to be aware of, and what to do about a missed dose. Some computer programs also print out an information sheet about your prescription.
When you enter the pharmacy, you will find that prescription card and diabetes supply programs pay for a 30 day supply and the correct days supply must be transmitted over the modem. Your insurance company’s computer will then perform the Drug Utilization Review (DUR) process and check for Therapeutic Duplications (two drugs for the same use), over utilization (filled too soon), under utilization, (skipped doses) and other generic and formulatory drugs that could be used instead. For example, people with diabetes, that break a vial of insulin or want an extra supply for an earthquake emergency kit, will have to purchase it themselves. Most insurance programs will not cover additional supplies. Vacation supplies often present a similar problem too.
Medical or diabetes supplies are usually not part of your prescription card plan. many programs require the patient to pay the pharmacy then send the receipt to them for 80% reimbursement.
Your pharmacist should have a supply of the appropriate insurance forms required by your plan and complete them for you. Payment is usually within a month. My personal insurance plan works this way.
I always enter the purchase information for diabetic supplies in our computer so I am able to provide receipts and keep a permanent record of the sale if needed later. Some plans require a letter from your physician or a Certificate of Medical Necessity for special items such as Blood Glucose Monitors and Insulin Pumps.
Most suppliers of diabetes supplies have preprinted forms to assist you in obtaining authorization for your Durable Medical Equipment needs.
Suppliers are required by federal regulation to file claims for Medicare recipients who inject insulin and purchase a Blood Glucose Monitor (purchase price minus rebate), test strips, control solution, and lancets. patients cannot file the claim themselves.
When your employer chooses a health insurance plan, you both agree to follow the program. Pharmacies also sign an agreement and must follow the specific plan and agree to the plan limitations.
Limitations are usually based on the number of days supply and whether it is generic or brand name. More and more plans are including a formulary or list of approved drugs.
Some time ago, a prescription card company conducted a field audit of my pharmacy. The auditor looks at each prescription which they have paid on behalf of the insurance plan. The only area of concern was the documentation of the number of days supply of insulins, syringes and test strips dispensed. As stated most insurance programs require that no more than a 30-day supply be given monthly. Often that is difficult to determine. Calculating a month’s supply of tablets given so many times per day is easy. Products that are self-administered according to blood glucose levels are not.
The 30 day supply must be calculated from the number of units of insulin injected each day, the number of injections, and the number of tests ordered by your physician. What the patient tells us does NOT document the physicians directions according to the insurance plan. These plans demand pharmacies to rewrite specific directions from your physician and will NOT accept “Use as Directed.”
Remember, along with your insurance company requirements, the Board of Pharmacy and proper counseling guidelines require that the physicians directions and refill information be clearly indicated.
The future is managed care which in reality is managed costs. People with diabetes, including myself, must be more vocal and assertive when requesting that new modalities be included in their care. We have the ADA Standards of Care and the results of the Diabetes Control and Complications Trial (DCCT) on our side. If your endocrinologist prescribes new therapies do not give up. Write letters, keep calling, and quote studies.
Someday soon pharmacist inventions will be clearly documented over the modem! Then and only then will your community pharmacy receive payment for all the services they perform.