Greed.. the Mother of all BASTARDS ?

I just finished exchanging emails with a pt in Florida… it would seem that the only place that this particular pt could get his/her opiates filled was a independent pharmacy for CASH !

This month the pt was greeted with the news that monthly medication cost had gone from $1824 to $2185.  This pt had been submitting the claims to his/her insurance company for using a non-network pharmacy.. and was using the money from previous month’s claim to help pay for this month’s supply. Needless to say, this pt didn’t have enough cash on hand to get the needed medication, but had to wait until spouse was off work  to get the additional funds – and after the pharmacy had closed for the day …

I suggested that the pt check his/her insurance website… so see if this particular pharmacy was actually a network pharmacy.. AND… GUESS WHAT ??? IT IS !!

It has been a while since I have seen a PBM contract… and I doubt if they have gotten more lenient in terms… but.. as I remember.. pharmacies with a contract with a PBM is not allowed to charge the pt cash for any service that should be included in the filling of the Rx .. nor.. charge more than the charge allowed by the PBM… nor decline to fill the PBM and charge the pt CASH !

So what options does the pt have at this point ?

1. Contact the insurance company and inform them that one of their contract pharmacies if refusing to bill the PBM for the pt’s covered medications.

Consequences for the Pharmacy:

The PBM could send the pharmacy a certified letter telling them to cut the crap out and honor their contact

The PMB could come and audit the pharmacy and attempt to clawback a boatload of money for violating their contract

The PMB could just cancel the pharmacy’s contact

Pt could ask their agent to do an anonymous call to the insurance company as to the status of the pharmacy’s contract with the PBM and if they are allowed to not bill covered Rxs and charge the pt CASH..

If answer to the above is YES… pt has the option of have a private conversation with the PIC/RPH and inform him/her of the pt’s understanding of the PBM contract and that unless the pharmacy wishes to fill/bill the pt’s prescriptions into the future. That the pt will file a complaint with the Insurance company, contact the media, and engage any attorney to file suit for all of the previous overcharges. Because the pharmacy/pharmacist maybe involved in insurance FRAUD !

Does that type of fraud come under “whistleblower” and RICO ?  I guess, the bureaucrats will just have to figure this one out..


2 Responses

  1. We are SO used to jumping through hoops, most of us would just pay for the meds and chalk it up to normalcy. Thank you Steve for all of your wonderful information.

  2. How much more discrimination and abuse most the sick and Disabled take? Between trying to live off disability, to trying to find adequate medical care and then trying to find a pharmacy that will fill prescriptions? Steve, is it possible for a monthly medication bill to be so much? Price gorging? I know most of mine are generic but the ones that aren’t don’t get filled as often as I should. But with doctors that are kind help by writing for 90 days after I explain that I pay the same for 90 days as 30. Our great government forces me to pay 3 times as much for schedule medication by their 30 day limit. Even though I have been disabled for almost 20 long long years. Will enjoy hearing the end of this story. Thanks for sharing the options.

Leave a Reply

%d bloggers like this: