Can Cvs do that ? It is legal

[ancienbon]

Over the past few weeks i have noticed that some medicare part D stopped paying for most of the test strips at CVS . When we process the claim, we get a rejection stating that insurance will only pay for True test, and true track. Today i received a call from a part D (humana) asking me to process a test strip claim for patient. ( Patient had called telling them about the rejection, which they did not see). I ran the claim, and still they did not see anything at all. So i had to call cvs help desk, who told me that it is cvs that rejected the claim because humana does not reimburse them at all or they are losing money, so they are forcing patient to get different brand. They did give me an override code for one time only.
Is this legal?

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[MountainPharmD]

Over the past few weeks i have noticed that some medicare part D stopped paying for most of the test strips at CVS . When we process the claim, we get a rejection stating that insurance will only pay for True test, and true track. Today i received a call from a part D (humana) asking me to process a test strip claim for patient. ( Patient had called telling them about the rejection, which they did not see). I ran the claim, and still they did not see anything at all. So i had to call cvs help desk, who told me that it is cvs that rejected the claim because humana does not reimburse them at all or they are losing money, so they are forcing patient to get different brand. They did give me an override code for one time only.
Is this legal?

Human's reimbursement on test strips is ridiculous. I've searched every secondary wholesaler and discounter I can find and the best price I can get on Contour Next test strips, which by the way Humana says is a preferred product, results in a $29.00 loss. Using the best price from my primary wholesaler results in a $129 loss. I have to use the Contour Next because he has an insulin pump that interfaces with the Contour meter.

 

[FlavyFlav]

Is it legal for a company to choose not to fill a prescription at a loss? I really don't think so. If an insurer is not willing to pay enough to keep from losing money, then why would the company accept it? If the patient really wants it, they can pay cash price or go to another pharmacy where the insurance will be accepted. The prescription isn't being denied. You could technically still fill it and the patient would have their strips. This happens all the time in the pharmacy world, whole plans aren't accepted at places due to reimbursement issues. A pharmacy does not legally have to take insurance and an insurer does not legally have to reimburse anything to a pharmacy without a contract in place.

In the end, it's all just business. Dollars are more important than people. Welcome to America.

 

[SClENCE]

Sure it's legal. They are not forcing the patient to do anything nor is the pharmacy denying them of the test strips. They can pay cash, get the other brand, or go elsewhere and ask some other pharmacy fill their prescription at a loss.

 

[SpartanLaser]

Some folks use the medicare dme test strips. Those cost as low as 8 bucks a box for 100

 

[ChalupaBatman86]

I think the problem is that it's intentionally deceptive. The messaging leads the pharmacist to believe that the plan does not cover it. The pharmacist tells the patient and their doctor that the insurance doesn't cover it, and persuades them to switch to a product that is more profitable for CVS. If the patient was given accurate information, that CVS won't fill the product due to low reimbursement, the patient might choose to use a different pharmacy or mail order to get their preferred strips. The pharmacist is unknowingly doing the dirty work to keep the customer at CVS and increase profits.

 

[PharmdA07]

Some folks use the medicare dme test strips. Those cost as low as 8 bucks a box for 100

Quick Question: Is it true that you can only dispense these DME strips to medicare & medicaid & tricare patients (government-assisted program) and not privately insured or cash-paid patients? I am so confused about this.... thanks in advance

 

[PharFromNormal]

Quick Question: Is it true that you can only dispense these DME strips to medicare & medicaid & tricare patients (government-assisted program) and not privately insured or cash-paid patients? I am so confused about this.... thanks in advance

Not sure on this specific example but I'd lean towards yes. If the product is supplied to you for low cost (because of a government subsidy program) there are oftentimes stipulations requiring you to use that product for patients with government assisted healthcare.

For example some states supply pharmacies state funded vaccine that can only be billed through state paid programs. Granted it might be the same vaccine you would use for your commercial pay population, you are often times required to keep separate inventories (also see: 340B)

 

[ancienbon]

I think the problem is that it's intentionally deceptive. The messaging leads the pharmacist to believe that the plan does not cover it. The pharmacist tells the patient and their doctor that the insurance doesn't cover it, and persuades them to switch to a product that is more profitable for CVS. If the patient was given accurate information, that CVS won't fill the product due to low reimbursement, the patient might choose to use a different pharmacy or mail order to get their preferred strips. The pharmacist is unknowingly doing the dirty work to keep the customer at CVS and increase profits.

You got it right.

 

[Aznfarmerboi]

Over the past few weeks i have noticed that some medicare part D stopped paying for most of the test strips at CVS . When we process the claim, we get a rejection stating that insurance will only pay for True test, and true track. Today i received a call from a part D (humana) asking me to process a test strip claim for patient. ( Patient had called telling them about the rejection, which they did not see). I ran the claim, and still they did not see anything at all. So i had to call cvs help desk, who told me that it is cvs that rejected the claim because humana does not reimburse them at all or they are losing money, so they are forcing patient to get different brand. They did give me an override code for one time only.
Is this legal?

For future references... if you see the rejection **CVS**- it is a rejection from CVS, and not from the insurance.

 

[ancienbon]

For future references... if you see the rejection **CVS**- it is a rejection from CVS, and not from the insurance.

Thanks. Now i know

 

[SClENCE]

I always get the *CVS* rejection when I'm trying to switch from generic to brand per patient request. Is there any way to override this without getting a DAW 1? I indicate that the patient requested brand in the "additional information" field but CVS often blocks it.

I even called MD to get DAW on one of these and THEN the insurance rejected it too. Nothing I can do about this but if CVS hadn't blocked it in the first place it would have saved me the hassle and I wouldn't feel like an idiot asking doctors for a DAW because of our garbage system. I fully understand the purpose of this feature but CVS needs to give us a little more room and information so that we can use our own judgement in these situations.

 

[Wheresmyaricept]

I always get the *CVS* rejection when I'm trying to switch from generic to brand per patient request. Is there any way to override this without getting a DAW 1? I indicate that the patient requested brand in the "additional information" field but CVS often blocks it.

I even called MD to get DAW on one of these and THEN the insurance rejected it too. Nothing I can do about this but if CVS hadn't blocked it in the first place it would have saved me the hassle and I wouldn't feel like an idiot asking doctors for a DAW because of our garbage system. I fully understand the purpose of this feature but CVS needs to give us a little more room and information so that we can use our own judgement in these situations.

You couldn't just run it through as Daw1 before you called the doctor to see if it was even covered? Just reverse it after you run it through. Sounds like you shot yourself in the foot there.

 

[SClENCE]

You couldn't just run it through as Daw1 before you called the doctor to see if it was even covered? Just reverse it after you run it through. Sounds like you shot yourself in the foot there.

I ran it through as "generic not in stock" and they covered it... I was going to just leave it like this but decided I should do it properly. Never thought to run it as a DAW1 too seeing as they covered it with the other option but that was my mistake.

 

[PikminOC]

My patient today said her test strips were 1.30 each. I was taken aback. That's a lot of money!

 

[SClENCE]

My patient today said her test strips were 1.30 each. I was taken aback. That's a lot of money!

Does she have insurance? Most patients would make a big scene and demand that we call the insurance to see what brand is covered then call the doctor to switch it on the spot (at 8pm).

 

[PikminOC]

She has insurance. Weird eh? And she is very savvy about cost and making sure things cost less.

 

[SClENCE]

She has insurance. Weird eh? And she is very savvy about cost and making sure things cost less.

My guess is that they are not covering the specific brand because 1.30 a strip is pretty much the out of pocket cost for most strips.

 

[PikminOC]

My guess is that they are not covering the specific brand because 1.30 a strip is pretty much the out of pocket cost for most strips.

She has a pump. I have no idea why she cant change..
She is looking into getting a sensor.

 

[SClENCE]

She has a pump. I have no idea why she cant change..
She is looking into getting a sensor.

Just write a new script for test strips and a new script for a meter without a specification on which brand to dispense. The pharmacy will dispense whatever is covered by the insurance.

 

[PikminOC]

I'm not the one writing for those. Thank goodness. I do think she would have talked to her Primary doc about it. IDK

 

[NateRobinson]

You guys call doctors to switch test strip brands.....?

I know, I know, legally, techincally you're supposed to, but do you think any doctor in their right mind would say "NO I WILL NOT AUTHORIZE A SWITCH FROM ONE TOUCH TO FREESTYLE. THEY MUST USE ONE TOUCH. IF THE INSURANCE DOESNT COVER IT, I DONT CARE. TELL THEM TO BUY IT."

That'll never happen, folks. I know, technically youre supposed to. But please save yourself the much needed time and just switch it. Make your life easy. Make the day go by nice and smooth.

Same goes for DAW on a levothyroxine when the patient has been getting synthroid for years and it's a friday night at 8:30 pm. JUST switch it...

 

[SClENCE]

You guys call doctors to switch test strip brands.....?

I know, I know, legally, techincally you're supposed to, but do you think any doctor in their right mind would say "NO I WILL NOT AUTHORIZE A SWITCH FROM ONE TOUCH TO FREESTYLE. THEY MUST USE ONE TOUCH. IF THE INSURANCE DOESNT COVER IT, I DONT CARE. TELL THEM TO BUY IT."

That'll never happen, folks. I know, technically youre supposed to. But please save yourself the much needed time and just switch it. Make your life easy. Make the day go by nice and smooth.

Same goes for DAW on a levothyroxine when the patient has been getting synthroid for years and it's a friday night at 8:30 pm. JUST switch it...

One pharmacist will switch test strips/inhalers, the other will not. I only act according to which pharmacist is there but I personally would just switch them too lol.

Do you guys document anything on the script like "ProAir okay per MD" or just change it?

 

[Ackj]

You guys call doctors to switch test strip brands.....?

I know, I know, legally, techincally you're supposed to, but do you think any doctor in their right mind would say "NO I WILL NOT AUTHORIZE A SWITCH FROM ONE TOUCH TO FREESTYLE. THEY MUST USE ONE TOUCH. IF THE INSURANCE DOESNT COVER IT, I DONT CARE. TELL THEM TO BUY IT."

That'll never happen, folks. I know, technically youre supposed to. But please save yourself the much needed time and just switch it. Make your life easy. Make the day go by nice and smooth.

Same goes for DAW on a levothyroxine when the patient has been getting synthroid for years and it's a friday night at 8:30 pm. JUST switch it...

Enjoy your Medicare B audit.

 

[socalpharm86]

Enjoy your Medicare B audit.

A prescription that meets all the part B requirements (tamper proof form, frequency specified, quantity specified, icd-9 written, hand signed, hand dated, and CMN form on file) will still get charged back for switching brands?

Please let me know if you have direct experience with losing money during a part B audit solely because of switching brands (when substitution is permitted) so I can adjust how I treat future part B prescriptions

 

[Old Timer]

Enjoy your Medicare B audit.

Medicare Part B does not have a formulary. These are private plans so switch away...

 

[Ackj]

A prescription that meets all the part B requirements (tamper proof form, frequency specified, quantity specified, icd-9 written, hand signed, hand dated, and CMN form on file) will still get charged back for switching brands?

Please let me know if you have direct experience with losing money during a part B audit solely because of switching brands (when substitution is permitted) so I can adjust how I treat future part B prescriptions

No verbal rx are allowed. If it's written as "One Touch" and you cross it out and put "Dr. OKs Freestyle" or something to that effect, that's not going to be valid. Just like when they don't include the icd-9, you can't just add it on there yourself, even with a verbal confirmation, you need them to resend the rx.

 

[radio frequency]

No verbal rx are allowed. If it's written as "One Touch" and you cross it out and put "Dr. OKs Freestyle" or something to that effect, that's not going to be valid. Just like when they don't include the icd-9, you can't just add it on there yourself, even with a verbal confirmation, you need them to resend the rx.

No verbal Rxs for Medicare part B? I am new at practice, but not familiar with that restriction. Where is it stated?

 

[owlegrad]

No verbal Rxs for Medicare part B? I am new at practice, but not familiar with that restriction. Where is it stated?

It started a few years ago now I think. Very annoying, but true. As for where is is stated, I have no idea.

 

[Old Timer]

No verbal rx are allowed. If it's written as "One Touch" and you cross it out and put "Dr. OKs Freestyle" or something to that effect, that's not going to be valid. Just like when they don't include the icd-9, you can't just add it on there yourself, even with a verbal confirmation, you need them to resend the rx.

But alas, this would only apply if the MD wrote brand x and the patient wanted brand y. Medicare part B pays for ANY brand of Strips/Lancets/Monitor. They work by procedure codes and not NDC #'s. So if it's Medicare Part D, or a Medicare Advantage plan, that requires a specific brand, switch away as Medicare Part B rules only apply to Medicare Part B claims.

 

[zelman]

No verbal Rxs for Medicare part B? I am new at practice, but not familiar with that restriction. Where is it stated?

5.2.2 - Verbal and Preliminary Written Orders
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
Except as noted in chapter 5 section 5.2.3.1 suppliers may dispense most items of DMEPOS based on a verbal order or preliminary written order from the treating physician. This dispensing order must include: a description of the item, the beneficiary's name, the physician's name and the start date of the order. Suppliers must maintain the preliminary written order or written documentation of the verbal order and this documentation must be available to the DME MACs, DME PSCs, or Zoned Program Integrity Contractors (ZPICs) upon request. If the supplier does not have an order from the treating physician before dispensing an item, the item is noncovered.
For items that are dispensed based on a verbal order or preliminary written order, the supplier must obtain a detailed written order that meets the requirements of section 5.2.3 before submitting the claim.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c05.pdf

For verbal orders, the physician must sign and return to the supplier a written, faxed, or electronic confirmation of the verbal order. On this confirmation the item(s) to be dispensed, frequency of testing, and start date (if applicable) may be written by the supplier, but the confirmation must be reviewed, signed, and dated by the physician.

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/SE1008.pdf

 

[Ackj]

But alas, this would only apply if the MD wrote brand x and the patient wanted brand y. Medicare part B pays for ANY brand of Strips/Lancets/Monitor. They work by procedure codes and not NDC #'s. So if it's Medicare Part D, or a Medicare Advantage plan, that requires a specific brand, switch away as Medicare Part B rules only apply to Medicare Part B claims.

Agree with you. But when a patient has been using brand X strips for years and had no intention/discussion with provider about changing brands, and you suddenly get an rx for a different brand, you're probably going to call and get it switched. Yes, you are certainly able to just bill for brand Y strips, and then get them a new meter to match, and show them how to use that new meter, etc, but that's probably not the best way to go. Making the switch on your own authority isn't going to work either.

Any other plan, sure, switch away.

 

[radio frequency]

5.2.2 - Verbal and Preliminary Written Orders
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
Except as noted in chapter 5 section 5.2.3.1 suppliers may dispense most items of DMEPOS based on a verbal order or preliminary written order from the treating physician. This dispensing order must include: a description of the item, the beneficiary's name, the physician's name and the start date of the order. Suppliers must maintain the preliminary written order or written documentation of the verbal order and this documentation must be available to the DME MACs, DME PSCs, or Zoned Program Integrity Contractors (ZPICs) upon request. If the supplier does not have an order from the treating physician before dispensing an item, the item is noncovered.
For items that are dispensed based on a verbal order or preliminary written order, the supplier must obtain a detailed written order that meets the requirements of section 5.2.3 before submitting the claim.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c05.pdf

For verbal orders, the physician must sign and return to the supplier a written, faxed, or electronic confirmation of the verbal order. On this confirmation the item(s) to be dispensed, frequency of testing, and start date (if applicable) may be written by the supplier, but the confirmation must be reviewed, signed, and dated by the physician.

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/SE1008.pdf

Thank you! Great info. Not sure how I didn't know.

 

[Van zandt]

I always get the *CVS* rejection when I'm trying to switch from generic to brand per patient request. Is there any way to override this without getting a DAW 1? I indicate that the patient requested brand in the "additional information" field but CVS often blocks it.

I even called MD to get DAW on one of these and THEN the insurance rejected it too. Nothing I can do about this but if CVS hadn't blocked it in the first place it would have saved me the hassle and I wouldn't feel like an idiot asking doctors for a DAW because of our garbage system. I fully understand the purpose of this feature but CVS needs to give us a little more room and information so that we can use our own judgement in these situations.

Use 00000009994 in the PA number field with any DAW other than a 5.

 

[ldiot]

Use 00000009994 in the PA number field with any DAW other than a 5.

How the heck do you know this stuff? lol

In regard to the OP; it's legal and in my opinion it should be legal. Why should a business be forced by law to fill prescriptions at a loss? The patient can switch brands, pay cash, or use another pharmacy. To the poster that said CVS is misleading; when it is CVS and not the insurance blocking the claim the rejection will say **CVS** indicating that it is CVS who is blocking it.

 

[Rukn]

It is perfectly legal to refuse to fill a script if you lose money on it

 

[lord999]

It started a few years ago now I think. Very annoying, but true. As for where is is stated, I have no idea.

(Ah, zelman beat me to it).

No verbal prescription regulation for Medicare A and B orders (5.2.2 and 5.2.3):

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c05.pdf

The rule is actually that a verbal order can be given but the dispense may only occur when the physical prescription arrives (just a C-II can be legally called in as a hold but can only be dispensed when the hard copy is presented by the patient).

 

[lord999]

I think the problem is that it's intentionally deceptive. The messaging leads the pharmacist to believe that the plan does not cover it. The pharmacist tells the patient and their doctor that the insurance doesn't cover it, and persuades them to switch to a product that is more profitable for CVS. If the patient was given accurate information, that CVS won't fill the product due to low reimbursement, the patient might choose to use a different pharmacy or mail order to get their preferred strips. The pharmacist is unknowingly doing the dirty work to keep the customer at CVS and increase profits.

So, it's a contract matter, and the standard contract is that a pharmacy may not selectively fill or not fill prescriptions if they are on formulary with the preapproved reimbursement. HOWEVER, CVS intentionally negotiates their contracts such that they are allowed to refuse prescriptions where the reimbursement falls beneath the AAC. That is a non-negotiating point for their contracts in Risk Management (having to deal with them for federal matters). It's a very intelligent business strategy that protects the company from them getting hosed by artificially induced shortages, medical devices like this, etc.

One thing though, for ones that come through true federal direct insurance (Tricare, VA Choice, IHS Fee), the contracts we have with the chains forbid them from refusing to fill them on grounds of reimbursement. Not that it actually happens in practice because the federal government with your tax dollars signs something called a "cost-plus" contract with the chains:

https://en.wikipedia.org/wiki/Cost-plus_contract

which means that CVS will quote some outrageous price (AWP flat even!) then add a percentage and we have to pay. No business on earth would ever consider such a contract, so it's up to the federal government to figure out how to blow up their own budget.

 

[ldiot]

(Ah, zelman beat me to it).

No verbal prescription regulation for Medicare A and B orders (5.2.2 and 5.2.3):

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c05.pdf

The rule is actually that a verbal order can be given but the dispense may only occur when the physical prescription arrives (just a C-II can be legally called in as a hold but can only be dispensed when the hard copy is presented by the patient).

So what's the ****ing point of giving the verbal order if it can't be dispensed and the patient has to bring a hard copy anyways?

 

[Van zandt]

How the heck do you know this stuff? lol

In regard to the OP; it's legal and in my opinion it should be legal. Why should a business be forced by law to fill prescriptions at a loss? The patient can switch brands, pay cash, or use another pharmacy. To the poster that said CVS is misleading; when it is CVS and not the insurance blocking the claim the rejection will say **CVS** indicating that it is CVS who is blocking it.

. I agree. When you have patients on Medicaid that " prefer the brand" without even understanding the generic is the same thing and Medicaid only is required to pay for the minimum generic so you lose out on the full cost for brand your store has to take the hit. It's bullsh*t. It drives me nuts when people do this.

 

[Van zandt]

Use 00000009994 in the PA number field with any DAW other than a 5.

Also in re to *CVS* message it's not always an actual block per say. It's just kind of like a heads up to let you know what's about to come next. Like aka, your stores gonna take a loss or, hey check this because it doesn't seem right. *CVS* messages are always able to get passed

 

[ldiot]

. I agree. When you have patients on Medicaid that " prefer the brand" without even understanding the generic is the same thing and Medicaid only is required to pay for the minimum generic so you lose out on the full cost for brand your store has to take the hit. It's bullsh*t. It drives me nuts when people do this.

Wow so they just reimburse you as if you were dispensing generic? My state medicaid flat out won't cover it.

 

[Van zandt]

Wow so they just reimburse you as if you were dispensing generic? My state medicaid flat out won't cover it.

Yup. Not to mention some of the patients who know they legally have the right to refuse copay and you have to override to zero. Humana did this too with their testing strips n crap that's why I found out CVS puts a block on them.

 

[lord999]

So what's the ****ing point of giving the verbal order if it can't be dispensed and the patient has to bring a hard copy anyways?

Because depending on what you're dispensing (a very hard to find form of CPAP, for instance), hospitals will call around looking for that exact one if it means that they can discharge a patient today. It's quite a normal state of affairs when you're not in a major metropolitan statistical area to only have 1 Walgreens and 1 CVS in town (if even that) if that and overstocking is highly discouraged in rural areas by the Big Three wholesalers. In ye olde days in Flagstaff, we kept a specific brand of CPAP for one hospital and another specific brand for the feds and having it in stock meant the difference between discharge and another day of inpatient charged to the state Medicaid fund. Reservations accepted!

In a major metropolitan though, your perspective that verbals are a wasteful idea is reasonable considering that there should be one of the Big Three in town that can drop ship to either a pharmacy or a DME supplier within the business day.