PDP Balance Billing?

vic120

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I have a supp client who I also helped enroll into PDP through Medicare.gov, Has a drug (tramadol) when he went to pick up at pharmacy, They told him that Ins company does not reimburse enough and that they have to bill him and addition $10 on top of copay for this med.

This is a local pharmacy not CVS or walgreens, However they are a preferred in network not just in network.

They also told him it would not matter if he had AARP or any other PDP that the drug had recently changed class level and no PDP pays enough and they are billing customers the difference

I have never heard this before and didn't even think that pharmacies can balance bill, however stranger things have happened. Does anyone else have any insight is this legit or not?
 
If there is a telephone number specifically for RX on the back of their card tell them to call it and either report it or ask if their contract with such and such pharmacy has changed where they can balance bill.

The purpose of using an in network provider is not to get balance billed.
 
If there is a telephone number specifically for RX on the back of their card tell them to call it and either report it or ask if their contract with such and such pharmacy has changed where they can balance bill.

The purpose of using an in network provider is not to get balance billed.

That is what I thought, The Pharmacy still claims the be a perferred in network provider (not just in network ) the same on medicare.gov

I will have him call cigna
 
I have a pharmacist fishing buddy. Medicare part D has extremely low margins on some medications and even force the pharmacies to lose money on some. The pharmacy has the option to "not fill" the medication, but that creates a business operating issue. They typically make a client by client decision on the other medications they fill if they can afford to lose on a few to profit on the many.
 
Don't they have a contract that they have to abide by? If not, then how can we trust anything the insurance companies put out regarding coverages.
 
Are they balance billing or tacking on a dispensing fee?

The way it was put to the client was because the reimbursement on this med is so low, That he would need to pay an additional $10 for this drug on top of copay each time prescription is is filled.Client asked if it was on cigna's end and he was told all the PDP's pay too low on this med and he would still have to pay the extra.

That to me sounds like balance billing but the specific word balance billing was not used.

Again as a side note from what the client told me this drug recently had a class change. I don't remember from what to what but tighter regs have been added to this drug as of recent
 
Based on your description my guess is still a dispensing fee. This article speaks to low Medicaid reimbursement but can also apply to Medicare.

http://www.nytimes.com/2011/10/14/us/lower-medicaid-dispensing-fees-may-pressure-pharmacies.html

Just like doc offices are now charging a fee for medical records and other services, I would not be surprised if pharmacies do likewise and charge a fee on top of the copay.

You will probably see this in a mom & pop store before the chains move in that direction.

Your client(s) should ask if the $10 is a dispensing fee. If so, they can move their Rx to another pharmacy or try to negotiate with the store owner.

FWIW copay's for Rx plans are not set in stone. In addition to tier movement there is usually a disclaimer saying the copay is an estimate.
 
I don't know about any other state, but CVS tried to add a dispensing fee here in MA a few years ago when the state started taxing the prescriptions. It was ruled illegal to charge more than the insurance copay and CVS had to refund all of the fees they collected...they can add dispensing fees on cash customers and negotiate it into their contracts with the insurance companies, but they can't charge above the copay for anyone that has insurance.
 
Something just came to mind, remember the first year the donut hole started to close? Well when you were in the donut hole there was a $2.00 dispensing fee when the manufacturers paid their part. I think it was 50% of brand and you pay the other 50 but pharmacy's were allowed the $2.00 fee. But that was only brand and you had to be in the donut hole.

I still say the only way they could charge an extra fee if they are in network is with the carrier's blessing. Otherwise they have broken their contract with carrier.
 
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