Getting Prescriptions Approved

A common customer complaint in retail pharmacy is why a prescription takes so long to fill. “Just put the pills in a bottle and slap a label on it!” Well, if it were only so easy, but there is thing small, insignificant thing called insurance. Note that last sentence was sarcasm. Some insurance claims can turn a two-minute prescription fill into hours…sometimes days. Yes, days. If a prescription requires prior authorization first, then you must first get that authorization from the doctor….which can take days.

Common Rejections

• Drug is not part of patient’s formulary
• Prescription requires prior authorization
• Refill request is too soon
• Insurance will not cover quantity written
• Insurance plan is no longer valid

Sometimes these issues can be solved by calling the insurance company, but depending upon volume of customers and staff, a call to the insurance company (and subsequently getting put on hold by the insurance company), which also may or may not also require a call to the doctor’s office, will put a kink in your productivity.

Insurance Cards

A common occurrence, especially after a new year begins, is updating a customer’s insurance information. Key pieces of information you will need from the insurance card is the the:

• BIN: biller indentification number
• PCN: processor control number (not all cards with have this)
• Group ID: differentiates plans offered by a company
• Member ID: identifies patient covered
• The back of the card: contains insurance contact information for when the information on the front of the card does not cooperate

Insurance Terms

Additional pharmacy insurance terms to know:

Adjudication is the process of a claim being received by the plan provider, who will determine if the claim will be accepted or rejected

Coordination of Benefits (COB) involves more than one insurance plan. A patient might have more than one form of insurance where it will need to be determined which is primary and which will be considered secondary. You will see this often when a patient has a savings coupon for a specific medication.

Co-pay is the portion of the cost that is not covered by insurance; the patient’s out-of-pocket expenses.

Deductible is the out-of-pocket expense minimum required before insurance will pay for any expenses.

Dependent is the spouse and/or children of policyholder who are covered under the insurance policy.

Pharmacy Benefit Manager (PBM) handles drug benefit programs; a PBM also processes and pays pharmacy claims.