Why won’t the pharmacy bill my insurance ?

DEFINITIONS

If you go to a pharmacy and they say that they will only fill your prescriptions for cash or just won’t offer to fill your prescription at all..

The first thing that you need to do is go to your insurance company’s website and see if this particular pharmacy is part of the insurance company’s pharmacy network.

If this pharmacy is part of your insurance company’s network.. then this pharmacy has signed a contract with your insurance company or the PBM that your insurance company is using to adjudicate pharmacy claims. This pharmacy has agreed to fill/bill prescriptions presented to them by the people that they insure and also agrees not to charge the pt more than the approve amount by the insurance company.

So refusing to fill your legit/on time/medically necessary Rx would be in violation of their contract.. as would be refusing to bill but willing to provide the medication for cash.  Here is a template/boiler plate letter for the pt to send to your insurance company.

As a pt, your options … call you insurance company and tell them that you expect them to find a pharmacy to fill/bill your prescriptions… or you can send a letter to the legal/compliance dept .. here is a template to use   Rxforcash

If your insurance company declines (blows you off )  to make their pharmacy network to honor their contracts.. or find a pharmacy that will fill/bill your prescription… then your insurance company may be committing fraud – accepting money (premiums)  to provide products/services and they have failed to follow thru.

Then you only choice is to file a complaint with your state Insurance Commissioner http://www.naic.org/state_web_map.htm

If your medication insurance involves Medicare Part D and/or Medicaid then filing a complaint with CMS is called for http://www.medicare.gov/claims-and-appeals/file-a-complaint/complaints.html

5 Responses

  1. BTW many health Ins policies R completely independent of the state Ins Commissioners office, policies called self insured R in this category. Also the Insurance Commissioner will refer to the Atty Gen office where they will tell U they take action if the complaint is a class action issue as they do not get involved with individual complaints…

  2. Steve you are priceless,… A national treasure for our people in pain being abused. Thank You !!

  3. If you force a pharmacy ( especially Mom and Pop pharmacies) to use your insurance when the insurance reimburses the medication at below cost (I’m not even talking at cost, I’m talking about losing money) then the pharmacy has no reason to reoder that medication or to keep it in stock. You may just find yourself not able to fill your medication at all. You could ask to fill the medication for the cash price and then get a printout to send in to the insurance for reimbursement yourself. You may not like this but at least you can get your medication this way. Until Obamacare goes away this may be your best bet to keep getting your meds.

    • This issue is not related to Obamacare. It was the same way b4 the bill was passed. Blaming everything on Obamacare just isnt going to work!

  4. […] Why won’t the pharmacy bill my insurance ? […]

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