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Insurance Questions in retail pharmacy

Discussion in 'Pre-Pharmacy' started by Citsouca1988, Dec 13, 2008.

  1. Citsouca1988

    2+ Year Member

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    I am a technician at a local cvs. Customers have been asking me some questions that I don't quite understand even when the pharmacists answers them clearly to me. Maybe I just don't click well the first time. Mainly its all about insurance issues.

    The first question is why does the copay go up with one medication even if the quantity, strength, and directions are the same than the last same medication? Of course, I told the patient/customer she would need to call the insurnace company and we don't deal with the copays but she seemed very lost and confused. Anyways, I nicely called the insurance company and they told me the drug price went up and they still take the same certain percentage off of it. I guess that answers my first question but how do they calculate the price? Do the prices vary from one insurance company to another?

    My second question is what are deductibles? I guess sometimes on a new year when insurance plans are activated, many patients have a deductible and they have no clue what they are. I was told that a deductible is when the insurance company won't cover the entire drug than usual until the patient purchases "X" amount of dollars in prescriptions in order for them to be covered fully by the insurance company. Is that right?

    Many customers/patients are very lazy to call themselves. -_-
     
  2. Sparda29

    Sparda29 En Taro Adun
    Pharmacist Classifieds Approved 10+ Year Member

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    If you go to the last screen in "QT" when you pick a prescription to print, it shows you a nice table of how much the drug costs, how much they are paying, and any adjustments they are making to the copay.

    If it's the same drug, with the same quantity and directions and the price went up, then the price went up on the drug and the insurance company has a higher copay.

    If they are different drugs, then it is because each drug is classified into tiers by the insurance company. Most insurance companies are likely to cover Simvastatin(Generic Zocor), Pravastatin(Generic Pravachol), Lovastatin(Generic Mevacor).

    However, most won't cover Crestor at all and maybe won't cover Lipitor.

    Deductibles, that is a certain amount of money that the patient has to pay out of pocket before the insurance kicks in.
     
  3. dmd20000

    10+ Year Member

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    if 1 insurance company covers lets say 50% of the drug and the drug went up then the patient must pay more because the insurance is paying the same amount each time.
     
  4. ajh88

    ajh88 New Member
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    The price is what you submit to the insurance company as the charge and what your company and the insurance company have agreed that you will be paid for the prescription. Yes, this varies from one insurance company to another. As Sparda said, there should be a summary screen where you can see the breakdown (I don't know what it looks like for CVS, but I'm sure there must be one).

    The co-pay can be either flat fee or percentage. Flat fee shouldn't change except at the beginning of a new insurance year (if the plan has changed). Percentage may vary from time to time if the price of the medication fluctuates (for example, 20% of $50 is more than 20% of $40). Both of these may change if the insurance company re-classifies the medication, say from "preferred" to "non-preferred".

    And the deductible is the amount of money a patient must spend out of pocket before they are eligible for insurance benefits. Some companies also have yearly maximums, so after they have paid a certain amount of money, the patient has to pay for everything themselves (not so great when the patient has hundreds of dollars worth of prescriptions each month!).
     

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