Usually it's same for both. Most copays are determined by the nature of the drug (i.e. brand vs. generic vs. nonformulary/nonpreferred brand), not by the amount prescribed. It's always 1 copay per 30-day supply.
Unless you have crappy insurance: some plans make you pay a percentage, and others consider 28 days' worth to be a month supply. Still others will only let you get 15 days at a time, or will limit the total number of prescriptions you can get per month. Others (like my school's student insurance) have a really low cap on the total dollar amount they will cover. There seem to be an infinite number of ways in which insurance companies can avoid providing adequate coverage. And unfortunately in retail pharmacy we see them all.
Well....kind of.....
I do hate to belabor points - but these are prescribers & future prescribers so we need to be honest here.
We are subject to audits constantly - in 2006, I had 4 audtis from 4 different insurance companies - about 100 pts each. Sounds like not so much - right? Except - I had to find each original rx, each documented refill (the pharmacist's notations of fill), each fill's receipt by the pt or pt's representative's signature....so accuracy is of primary importance. Each audit took me 6 hours to complete. If I could not document each item on the audit - the insurance company had the ability to nulify payments on ALL pts who were on the audit request. Sounds irrational? Yep!
Take your TAC 0.1% cream - 30Gm - apply qd ud - no problem- I can put a 10, 15, 30 or whatever day supply on that I want to make it fit the insurance.
But...if its now a psoriasis pt - if I'm going to be billing Dovonex 120Gm rather than 60Gm - I have to document on the rx the product will be applied to sufficient surface area that 120Gm will last only 1 month. Now, you might ask - so just do it - but now the insurance companies are requiring documentation from phsycian's offices that indeed 120Gm is just a 30 day supply (which implies a substantial body surface area involved). If & when the physician documents that - then the physician is subject to audit - many don't want that so are reluctant to provide that substiantion. Also, if the drug is not ordered on a monthly (or 60 day, 90 day, etc basis consistently & the physician documentation doesn't correspond), my claim will also get rejected. Likewise - some insurance companies will decide it doesn't matter how much is ordered - they will limit their payment to only a certain quantity per month - happens to Norvasc, paroxetine & ppi's all the time - if you want your pt to take it twice a day - since it is designed as a once a day dose, unless you get a prior auth - the pt pays for the second dose per day & the insurance pays for one dose per day. Even if you get a PA, they may still say they only will pay so much per month - I've got 2 thalidomid pts who fall in this category - the bill is $1980/mo yet the insurance will pay a max of $500/claim.
In the case of eye drops, ear drops or inhalers - the droppers & delivery devices are calibrated & the sig must match the days supply. Just because you want to give 3 Patanol's for a 30 day supply doesn't mean it will happen because we know how many drops you prescribe & how long the bottle will last. Yep - waste & "dripping" are included, but 3ml (actually 2.5) of Xalatan lasts 1 month for normal dosing - anything extra might require a PA.
So....you think you can get around it by giving a sig - use as directed. Aaaah - within the practice of pharmacy - that will automatically get a denial of payment. Which is why we need to get the exact sig & is why we want to get the dosage change correct when you tell the pt to take 1 more tablet or use once more per day. Use as directed doesn't fly anymore - it must match your last documented recommendation in your chart.
Now...not all insurances only allow a 30 day supply. In fact, almost all Medicare Part D plans allow for a 90 day supply. Some private plans allow for 60-90 days - it depends on what the employer "buys" for it employees.
As for copays - currently, they are "tiered". That means for any one drug class - lets say topical steroids, statins, antibiotics - there are some on generic forumlary (lovastatin, pravastatin), some brand formulary (lipitor) & some non-formulary (crestor). Each has its own co-payment structure. Again - this is not defined - it is determined by the plan & the plan is often determined by how much the employer wants to spend rather than the employee (if you're a student - you spend little - thus you get little).
So - as Samoa said earlier - far too complicated. But, really rx insurance, reimbursement & coverage is complicated - for the pt & the prescriber. But - at this point in time, there is nothing we can do but deal with the system we have which is fractured at best. But - on the prescriber's end - you must be able to document that what you tell me is indeed correct because they can & do audit us both. Periodically, there are publications for those who are under investigation for Medicare/Medicaid fraud & if you got caught in one, you'll get caught in private insurance fraud as well. It definitely not worth it to me & I can't imagine its worth it to you either.
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