You need to know your job in order to help others, if you don’t take the time to learn how can you know how to read a medication when has been rejected when an online claim is process.

For example

One of the major pharmacies here in the states is Walgreens and is my opinion that is one of the pharmacies that they don’t care too much. You might say why? Continue reading and I will explain why.

Every day we received calls from patients that they go to their pharmacy (Walgreens) and they are told that that the insurance is not active when in fact it is or that the medication is not covered, when in fact it is. If you are in that position ask them to please take the time to call the insurance company and actually verify if your insurance is active or if the medication that the doctor prescribe you is covered.

If the system is rejecting the medicine, usually is because the medication required prior authorization. If the Pharmacist or Pharmacy Technician just takes 2 minutes to call the insurance and provide the doctor’s name, phone number and fax number to start prior authorization it will save your lots of time. Don’t let them tell you that your insurance don’t cover that medication without making the call. Normally the idea is to charge you full price for the medication.

Most people can’t afford the cost of their medications, if we don’t help the patient who is going to help. It only takes a few minutes to call the insurance company to verify if required prior authorization and if that is the case. Is part of your job no matter if the pharmacy is crazy busy, or if you have a millions thing to do in the pharmacy, if you don’t like your job / profession get out. Is one of our commitments when we decide to study any health careers like in this case Pharmacy.

Bottom line is YOU the members’ responsibility to read and understand your insurance plan but must important your benefits.

Under the pharmacy benefits you should asked some of these questions:

• Copay structure for medications including local pharmacy and mail order pharmacy.
• Do you have mail order benefits and the name of the pharmacy they use as mail order.
• Maximum day’s supply you can get at local retail pharmacy and mail order pharmacy.
• If mail order pharmacy is mandatory on maintenance medications.
• Deductible and the amount, and if is per family or individual.
• Maximum benefits per year if any
• Out of pocket amount if any
• Which medications required Prior Authorization i.e. Singulair, ADD or ADHD medications, Injectables, Cosmetic drugs, Smoking Deterrents, PPI’s, etc.
• Medications that have quantity limits and what is the quantity i.e. Viagra, Cialis, Levitra, Imitrex, Relpax, Zomig, Oxycontin, Kadian, Ambien, Lunesta etc.
• Maximum dollar amount allowed per prescription, usually if the prescription cost is over that amount required Prior Authorization.
• Pharmacies in network.
• If the plan allow reimbursement and time frame to submit claims, usually is 365 days, if is allowed in pharmacies that are out of network
• If is mandatory to use a specialty pharmacy for injectables, if yes asked the name
• If you are a diabetic always ask for diabetic supplies, glucose meter, test strips and lancets
• If generic medications are mandatory
• The FORMULARY, with this list you will see which medications are preferred or non preferred under the insurance. Usually non preferred medication you can get them but with a higher copay.

Ask questions and don’t assume.