Pharmacy insurance (Oh, brother!)..it can turn a two minute prescription into a twenty minute one.

pharmacy insurance

If you ever played a certain popular video game from the 1980s, then you are familiar with this guy here on your left. You are just trying to complete your mission when he decides to get in your way. Not only is he in your way, he is also throwing an endless supply of hammers at you! Consider any pharmacy insurance scenario to be like that.

Think of insurance as the pharmacy version of a hammer brother. Insurance issues just pop up at inconvenient times and throw figurative hammers at you while you are trying to complete the task. Here are some 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

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) will put a kink in your productivity.

Insurance Cards (a whole ‘nother type of hammer)

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

Additional pharmacy insurance terms to know:

  • Adjudication: 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): 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: portion of the cost that is not covered by insurance; the patient’s out-of-pocket expenses
  • Deductible: out-of-pocket expense minimum required before insurance will pay for any expenses
  • Dependent: 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

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