This excerpt was taken from a certain PBM. Read the language and tell me how ridiculous this is.
Payment for compound claims will be based upon the Usual and Customary Retail Price submitted, or the submitted ingredient cost plus the preferred brand dispensing fee, whichever is less. Network Provider shall not be reimbursed for non-FDA approved ingredients, including bulk chemicals, used in compounding. In the event Network Provider uses only bulk chemicals in the compounding of a prescription drug, then Network Provider shall receive no reimbursement for such prescription drug. Notwithstanding the foregoing, in the event --- determines, in its sole discretion, that reimbursement for bulk chemicals is appropriate in a situation, then Network Provider shall receive the lesser of: AWP of the FDA-approved readily available product or AWP of the compound or bulk chemical(s)
So basically, when i run the claim at POS it rejects with a claim exceed Dollar limit. So i call this PBM and they get all the NDCs for the product, override it and the claims goes through. However, at the end, the Rep says, if this claim is audited and found to be in excess of plan limits, reimbursement will be reduced to what it should be, do you agree. I said yes because i made sure i submitted the compound correctly. However, after reading the above in the contract, i am convinced that this is a scam to get me to make the compound, the PBM pays, and then will retract payment later, keeping the money themselves. Then again, since i called the PBM and they overrode it, that to me is them saying to me that the ingredients are appropriate.
This is the sort of crap im talking about with these companies. Is it covered or not? If it is not, why override it? Why let it go through at POS? Just reject the damn claim. NDC NOT COVERED. For all of you who say PBMs are needed, i would be happy to post more language from certain ones and you can read for yourself how ridiculous it is to do business with them.
Discuss
Payment for compound claims will be based upon the Usual and Customary Retail Price submitted, or the submitted ingredient cost plus the preferred brand dispensing fee, whichever is less. Network Provider shall not be reimbursed for non-FDA approved ingredients, including bulk chemicals, used in compounding. In the event Network Provider uses only bulk chemicals in the compounding of a prescription drug, then Network Provider shall receive no reimbursement for such prescription drug. Notwithstanding the foregoing, in the event --- determines, in its sole discretion, that reimbursement for bulk chemicals is appropriate in a situation, then Network Provider shall receive the lesser of: AWP of the FDA-approved readily available product or AWP of the compound or bulk chemical(s)
So basically, when i run the claim at POS it rejects with a claim exceed Dollar limit. So i call this PBM and they get all the NDCs for the product, override it and the claims goes through. However, at the end, the Rep says, if this claim is audited and found to be in excess of plan limits, reimbursement will be reduced to what it should be, do you agree. I said yes because i made sure i submitted the compound correctly. However, after reading the above in the contract, i am convinced that this is a scam to get me to make the compound, the PBM pays, and then will retract payment later, keeping the money themselves. Then again, since i called the PBM and they overrode it, that to me is them saying to me that the ingredients are appropriate.
This is the sort of crap im talking about with these companies. Is it covered or not? If it is not, why override it? Why let it go through at POS? Just reject the damn claim. NDC NOT COVERED. For all of you who say PBMs are needed, i would be happy to post more language from certain ones and you can read for yourself how ridiculous it is to do business with them.
Discuss
