Reimbursements on packaged medications

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

ZakMeister

RPh
10+ Year Member
Joined
Dec 12, 2012
Messages
245
Reaction score
27
I am confused about how insurance reimburses packaged medications and would like someone clarify it for me.

To my understanding, let's say, creams and solutions which comes in different weights like 15g, 30g should have different reimbursement rates right? Does that work the same for solutions and broken insulin pen packages (e.g. 10ml of Novolog dispensed instead of the 15ml?)

Thanks :D

Members don't see this ad.
 
I am confused about how insurance reimburses packaged medications and would like someone clarify it for me.

To my understanding, let's say, creams and solutions which comes in different weights like 15g, 30g should have different reimbursement rates right? Does that work the same for solutions and broken insulin pen packages (e.g. 10ml of Novolog dispensed instead of the 15ml?)

Thanks :D
you would think a 15g tube will cost 1/2 30 g tube but might actually be 75% of the cost. every type of cream will be different. as for things like box of insulin pens i would never brake that packaging in my store so i cant answer how it would be reimbursed. i assume you will get the appropriate % . when i worked at chain i'd brake that box no problem not my money
 
  • Like
Reactions: 1 user
Members don't see this ad :)
It's all about contracts between PBM, manufacturer, pharmacy. I'll scratch your back on some lipitor if you give me a deal on Viagra. Cloak and dagger type stuff.
 
you would think a 15g tube will cost 1/2 30 g tube but might actually be 75% of the cost. every type of cream will be different. as for things like box of insulin pens i would never brake that packaging in my store so i cant answer how it would be reimbursed. i assume you will get the appropriate % . when i worked at chain i'd brake that box no problem not my money
Would breaking the box affect reimbursement in anyway? My pharmacist is the wisest person I know and he does that while other stores I know don't. What is your rationale?


Sent from my iPhone using SDN mobile
 
Would breaking the box affect reimbursement in anyway? My pharmacist is the wisest person I know and he does that while other stores I know don't. What is your rationale?


Sent from my iPhone using SDN mobile
i wouldn't break it because theres no guarantee i will sell the rest of the box and then it might just sit there until it expires. if you work for chain than who cares break the box all day long. in terms of reimbursement i would guess for this drug you would get paid the correct % meaning if box of 5 pens pays you $500. then 3 pens will get you $300, but this is just an educated assumption.
 
I'm gonna hijack this and ask something similar...

...say you got an Rx for Humulin 70/30 and an insurance demands Novolin 70/30. If I just switch it, will the audit fairy come and stab me in the ass 18 months from now?

They don't seem to care for switching between albuterol brands.
 
I'm gonna hijack this and ask something similar...

...say you got an Rx for Humulin 70/30 and an insurance demands Novolin 70/30. If I just switch it, will the audit fairy come and stab me in the ass 18 months from now?

They don't seem to care for switching between albuterol brands.
Funny , i had a fax audit for this exact scenario. but they were interested in it because 7 vials per month. and ofcourse just write in as per md ok to substitute.
 
I'm gonna hijack this and ask something similar...

...say you got an Rx for Humulin 70/30 and an insurance demands Novolin 70/30. If I just switch it, will the audit fairy come and stab me in the ass 18 months from now?

They don't seem to care for switching between albuterol brands.

Most offices don't document the change anyways so you just per ok to switch per md.
 
MTM Outcomes will pay a $10 TIP reimbursement if you switch a targeted patient from proair to ventolin as a cost saving measure. This is a much easier TIP than switching patients from vyvanse to generic adderal for cost savings.
I haven't had any patients complain about switching albuterol inhalers except for the proventil because it does not have a dose counter. Ironically proventil is the most expensive one. Anyone dispense a proair respiclick lately? Teva rep has been handing out free trial coupons for it this week and invited me to a drug rep dinner. Also forgot there was one patient who complained about the ventolin because the box was too big.

As for switching insulins, there was a rph in ohio cited for switching brands due to a prior auth. I will try not to switch the brand of insulin except if the patient is there and angry about needing it NOW at 10pm.
 
Top