Prolia Shot Part B or not??

[vic120]

I am sure my client had it fully covered I am sure of it

Just got of the phone with one of my more panicky clients she will call with more details tomorrow,

But she is telling me She got a bill from a pharmacy for prolia shot even though she got it at the docs office and did not pick it up at the pharmacy

Does anyone know about this ?? This cannot be legit right??

Another thing that baffles me is these weird things never happen outside of AEP for some reason

 

[somarco]

I am sure my client had it fully covered I am sure of it

Just got of the phone with one of my more panicky clients she will call with more details tomorrow,

But she is telling me She got a bill from a pharmacy for prolia shot even though she got it at the docs office and did not pick it up at the pharmacy

Does anyone know about this ?? This cannot be legit right??

Another thing that baffles me is these weird things never happen outside of AEP for some reason

At one time Prolia was covered under Part B. Not sure when it happened, or who put the squeeze on this, but now the Rx shows in the plan finder and it isn't cheap.

Maybe @kgmom219 has some insight

 

[DS4]

ALL my clients have Prolia covered under Part B. This pic is from Prolia website

 

[vic120]

Im going to find out tom morning

Seems weird But I have to get her to slow down to tell me

 

[somarco]

ALL my clients have Prolia covered under Part B. This pic is from Prolia websiteView attachment 7444

DS4 to the rescue again. I am a real AEP zombie right now.

 

[sshafran]

The crazy thing is the providers (docs / pharmacy) should be the ones directing the proper billing.

We are agents. We sell the policy.

They get paid for treating patients -- they should know how to properly bill for their services.

Vic should solve it then invoice the doctor's office for his time.

 

[somarco]

The crazy thing is the providers (docs / pharmacy) should be the ones directing the proper billing.

We are agents. We sell the policy.

They get paid for treating patients -- they should know how to properly bill for their services.

Vic should solve it then invoice the doctor's office for his time.

I had a lady that experienced the same thing about a year ago. Her doc wrote an Rx for her to fill at her pharmacy. She asked me about Prolia after the fact. I had just read an article where DC was trying to move more Rx from Part B to Part D, so I assumed this is what happened with Prolia.

Prolia IS covered by at least some PDP's. I don't recall her copay but she was not pleased.

 

[vic120]

The crazy thing is the providers (docs / pharmacy) should be the ones directing the proper billing.

We are agents. We sell the policy.

They get paid for treating patients -- they should know how to properly bill for their services.

Vic should solve it then invoice the doctor's office for his time.

Unfortunately, I do deal with issues from time to time, Docs and pharm's give clients a harder time knowing they don't know as much

This one she is an OLD 80 with a nervous condition and many health issues and no family,


I just spoke with her kind of confused, I don't seem to be getting a straight story, said she went to doc then got a call from pharm wanted to charge $358 then she balked switched her to another pharmacy and she paid $286

I Sia I thought you didn't go to the pharmacies HER I didn't they called me after the shot I didn't know what to do I paid them

Did the doc call or the pharmacy? HER the pharmacy

Me how then did they switch you to another pharmacy for a lower price

Her I don't know I don't understand any of this I am so confused

Finally going back and forth from there making less and less sense I said send me the bill to call the doc and see what the deal is

 

[kgmom219]

Prolia is usually covered under D. It can be Part B, though, too. It all depends on where the shot is billed. Most docs don't get the shot and bill it under Part B, so the patient gets the drug at the pharmacy and its D.

I hate Prolia. Its a BMA drug. Half the time, the client forgets to put it on their drug list. So I get a call 6 months later and I've got them on the wrong damn Part D.

 

[DS4]

the client forgets to put it on their drug list..

Truth!
The delivery setting usually determines whether B or D.