Frequently Asked Questions - pharmacy

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A pharmacy serves as a crucial link between insurance companies and patients. It handles the billing process for your medications, submitting claims on your behalf to your insurance plan to recover the costs of the medication that is given to you. The pharmacy receives immediate feedback on coverage details from the insurance company. However, it does not make decisions regarding coverage aspects such as deductibles, copays, or prior authorizations, and cannot make any changes to these details. If you have any disagreements or issues with the coverage information provided to the pharmacy by your insurance company, please contact your insurance provider directly for further details and resolution.  

Insurance is a legally binding contract between an individual or business and an insurance company. In exchange for a premium, the insurer agrees to cover the cost of services specified in the contract. Pharmacies do not play a role in this contract. Insurance companies provide only limited details to pharmacies, sharing only what they deem necessary. The insurance company is not obligated to discuss or provide details about your insurance contract detail to the pharmacy. If you disagree with the coverage details provided to the pharmacy by your insurance company, please contact your insurance provider directly for further information and resolution.

In general, copay does not change from pharmacy to pharmacy if billed through insurance benefits. Pharmacy bills on your behalf to your insurance plan. If your insurance plan remains the same, out of pocket costs remain the same at any pharmacy in the country. However, copay would be different in following scenarios.

• if you have commercial insurance and pharmacy is using coupon to reduce out-of-pocket cost. Please refer question about coupon use for further details.
• In another uncommon scenario, some insurance plans have preferred pharmacy networks. If you use a pharmacy outside of this network, your copay might be higher. 

 Yes, you can absolutely use coupons for your medications with us! We understand that saving money on prescriptions is important, which is why we accept a variety of medication coupons to help reduce your out-of-pocket costs. Whether it's manufacturer coupons, pharmacy discounts, or special offers, we're here to make the process smooth and hassle-free. Simply present your valid coupon at the time of purchase, and our team will take care of the rest. 

Following are limitations.

Commercial Insurance Plans:

• If your insurance plan is commercial (e.g., through work or self-pay), you can generally use coupons to help reduce the cost of your medications.
• Be aware that each coupon may have specific limits, such as monthly spend limit or annual spend limit.

Government-Funded Insurance Plans:

• For insurance plans paid for by the government (e.g., Medicare, Medicaid, VA, TRICARE), coupons cannot be used.
• This restriction is due to regulations that prevent the use of coupons with government-funded insurance plans. It is against the law to use coupon.

 Convert Prescription to Cash Price

• Pharmacies can offer patients the option to pay the cash price for medications when the cost with insurance is higher than the pharmacy's affordable medication program. This approach allows patients to bypass insurance pricing, which can sometimes be inflated due to co-pays or deductibles.

Use Copay Assistance Programs and Coupons

• Many drug manufacturers provide copay assistance programs to reduce out-of-pocket costs for eligible patients. These programs are often available for brand-name medications and can cover a significant portion of the copay.

Provide Guidance to Enroll in Community Foundation Programs

• Community foundations often offer medication assistance programs for individuals facing financial hardship. For example, organizations like Good Days and PAN Foundation provide financial support for life-saving treatments.

Provide Guidance to Enroll in Manufacturer Assistance Programs

• Drug manufacturers often have patient assistance programs (PAPs) that provide free or discounted medications to eligible individuals. These programs are typically designed for uninsured or underinsured patients.
• Pharmacies can assist patients in completing enrollment forms, gathering required documents (e.g., proof of income, insurance information), and submitting applications.

What is Prior Authorization?

Prior authorization is a process where your healthcare provider must obtain approval from your insurance company before certain medications, treatments, or procedures are covered. This ensures that the prescribed service is medically necessary and aligns with your insurance plan's guidelines.

Why Does Insurance Require Prior Authorization?

Insurance companies use prior authorization as a cost-control measure. It helps them verify that:

• The treatment or medication is necessary for your condition.
• Less expensive or alternative options have been considered.
• The prescribed service is safe and appropriate for your situation.

This process aims to prevent unnecessary spending and ensure that patients receive evidence-based care.

How Often Do Doctors Need to Do Prior Authorization?

Doctors frequently deal with prior authorizations, especially for expensive or specialized medications and treatments.  The frequency depends on the insurance plan and the type of care being provided. Most commonly prior authorization is needed every 6 or 12 months. 

 What role pharmacy plays in prior authorization? 

Pharmacies play a crucial role in the prior authorization process, acting as a bridge between patients, healthcare providers, and insurance companies. However, pharmacy does not have any role in decision making and approval timeline. 

Here's how pharmacy contribute:

1. Identifying Medications That Require Prior Authorization
   • Pharmacies notify patients and healthcare providers when a prescribed medication needs prior authorization. This often happens at the point of prescription processing, when the claim is flagged by the insurance company.

             2. Facilitating Communication

• Pharmacies help streamline communication between doctors and insurers. They often provide necessary guidelines, and information about the prior authorization requirements for specific medications.

             3. Patient Advocacy

• Pharmacies advocate for patients by ensuring that delays are minimized.
• Pharmacists may also inform patients about alternative medication options, including those covered without prior authorization, to avoid interruptions in treatment.

             4. Follow-Up and Monitoring

• Patient and doctor office receives communication from insurance once process is completed. We request our patient to reach out once they get status of approval. At pharmacy, we usually try to process claim after 3-5 business days of initiating process.

This collaborative effort helps patients access their prescribed treatments while navigating the complexities of insurance requirements

The Medicare Prescription Payment Plan is a new option starting in 2025, designed to help manage out-of-pocket costs for Medicare Part D prescription drugs. Instead of paying the full cost at the pharmacy, participants can spread their payments across the calendar year. This plan doesn't reduce drug costs but offers a way to manage monthly expenses. It caps annual out-of-pocket costs at $2,000, as established by the Inflation Reduction Act. Participation is voluntary, and all Medicare drug plans will offer this option. Please note that it's been implemented by your insurance company and would require to pay directly to your insurance company. 

Scenarios:

1. Annual out-of-pocket cost is about $1300 (Taking 1 Brand medication). You will pay full $1300 in small installment over the period of 12 months. 

2. Annual out-of-pocket cost is about $2400 (Taking 2 Brand medications). You will pay maximum of $2000 in small installment over the period of 12 months.

3. Annual out-of-pocket cost is about $3600 (Taking 3 or more Brand medications). You will pay maximum of $2000 in small installment over the period of 12 months.

No, we do not offer medication disposal program

We carry a wide range of over-the-counter medications for pain relief, allergies, cold and flu, digestive health, and more. Contact us to learn more.

Yes, you can refill your prescription online through our website. Simply use "Request a Refill" form on our website. 

A formulary is a list of generic and brand-name prescription medications covered by your health insurance plan. These medications are typically divided into tiers based on their type and cost. If your prescription medication is included in a lower tier, it will generally cost you less.

How It Affects Your Coverage:

• Tier System: Medications in lower tiers usually have lower copays or coinsurance, while      those in higher tiers may cost more.
• Plan Variability: Formularies can vary significantly between different insurance plans, so it’s important to check your specific plan’s list of covered drugs.
• Changes: Insurance companies can change their formularies at any time. This means a      medication that was covered might not be in the future, or its tier placement could change, affecting your out-of-pocket costs.

Update Frequency:

• Annual Updates: Most insurance companies update their formularies at least once a year.
• Biannual Updates: Some may update them twice a year or more frequently, depending on various factors like new drug approvals or changes in drug pricing.

If you have any concerns about your medication coverage, it’s a good idea to review your plan’s formulary regularly and contact your insurance provider for the most up-to-date information.

Covered Medications:

• These are generic and brand-name prescription medications included in your health insurance plan’s formulary.
• Being on the formulary means the insurance plan covers part or all of the cost, often      resulting in lower out-of-pocket expenses for you. Out of pocket cost will depend on multiple factors like Deductible, Copay, coinsurance, etc.
• Covered medications are typically divided into tiers, with lower-tier medications costing less and Higher tier medication costing more to you

Non-Covered Medications:

• These medications are not included in the insurance plan’s formulary.
• Insurance plans generally do not pay for non-covered medications unless there are special circumstances and prior approval is obtained.
• Insurance companies have strict criteria for approving non-covered medications, and these medications often fall into higher tiers, resulting in higher costs for the patient.

When your doctor prescribes a medication, they rely on basic formulary details shared by insurance companies with electronic medical records (EMR) providers. This helps them make informed decisions, but it’s important to note that:

•  General Information: The coverage information available to your doctor is not specific to your individual insurance plan. It reflects general formulary details at the company level (e.g. United Healthcare, Cigna).
• Updates: Formulary updates might not be immediately reflected in the EMR system. This is the most common reason for discrepancy between doctor office and Pharmacy information.

Pharmacy’s Role:

• When the pharmacy bills for your medication, they receive direct and up-to-date information specific to your insurance plan.
• This can result in the pharmacy informing you about copays, non-coverage, or the need for prior authorization

Covered Medication:

• When a medication is covered, it means it is included in your insurance plan’s formulary.
• Coverage Does Not Equal No Cost: Even if a medication is covered, you may still have out-of-pocket costs such as copays or coinsurance or deductible.
• Prior Authorization: Some covered medications may require prior authorization, meaning your insurance company needs to approve the medication before they agree to pay for it.

We recommend taking following action when receive such letter to make informed decision.

1. Read the Letter Carefully:
   • Pay close attention to the language used in the letter. Insurance companies often have their own pharmacy businesses, which are separate from their insurance operation.
   • Most of the time, these letters are solicitations aimed at persuading you to use their pharmacy to boost another line of business

             2. Check Your Insurance Policy:

• In some cases, you might have agreed to use their pharmacy when you or your employer purchased insurance policy. This would be a contractual obligation. If this is the case, you are required to use pharmacy preferred by your insurance company as part of your agreement.

             3. Confirm with Pharmacy:

• Our pharmacy can help confirm if there is an obligation in your policy that requires you to use the insurance company’s pharmacy.
• If such an obligation exists, you must use the pharmacy run by your insurance company.

             4. Contact Your Insurance Provider:

• If you have any doubts or need further clarification, it’s a good idea to contact your insurance provider directly. They can provide detailed information about your       policy and any requirements regarding pharmacy use

Medicare Supplement insurance policies do not include prescription drug coverage. Keep in mind that Medicare Supplement plans are designed to cover out-of-pocket costs such as copayments, coinsurance, and deductibles, but they don’t include coverage for prescription drugs. 

Original Medicare (Straight Medicare):

• Includes Part A (Hospital Insurance) and Part B (Medical Insurance).
• Allows you to visit any doctor or hospital in the U.S. that accepts Medicare.
• You pay a portion of the costs (like deductibles and coinsurance), and there’s no yearly limit on out-of-pocket expenses unless you have supplemental coverage like Medigap.
• Prescription drug coverage (Part D) is not included but can be added separately.

Medicare Advantage Plan (Part C):

• Offered by private companies approved by Medicare and bundles Part A, Part B, and often Part D (prescription drug coverage).
• May include additional benefits like vision, dental, and hearing coverage.
• Typically requires you to use a network of doctors and hospitals.
• Has a yearly limit on out-of-pocket costs for covered services.

Both options have their pros and cons, depending on your healthcare needs and preferences. Please note that once enrolled in Medicare Advantage Plan, you cannot revert back to Original Medicare (Straight Medicare). 

Unfortunately, there are no supplemental plans available to purchase to cover medication cost. However, you could try to see if you are eligible for Medicare Part D extra help program.

Medicare Part D provides drug coverage. The Extra Help program helps with the cost of your prescription drugs, like deductibles and copays. You can apply for Extra Help any time before or after you enroll in Part D. Application for EXTRA HELP can be completed online or calling on +1 800-772-1213