My pharmacy refused to honor my co-pay.

[AirmensMom]

Make that my EX-pharmacy.

I've used this pharmacy for 3 years. One of my meds costs $10/month co-pay through my insurance. I'm supposed to get enough for a month, but I ran out 3 days early. So I called the pharmacy to reorder and told them I was short. Nope, can't be. They don't make mistakes.

So I went over to pick up the Rx later and was charged $15. When I questioned them, they said the price had gone up for them, so it goes up for me. I called my insurance company when I got home and they told me that 1) the pharmacy never entered today's reorder into their system and 2) they are only supposed to charge me $10.

I called the pharmacy back and was told that they were losing money by letting me have my meds for $10 and they'd be stupid to keep doing it. They refuse to order them again unless I agree to pay $15. In other words, they are refusing to let me pay for my prescription using my insurance (which is probably why they never called it in) because they don't agree with the co-pay. I told them I'd be stupid to keep getting my prescriptions from them. Then I called the insurance company back and filed a complaint.

It got me thinking: I can afford the extra $5, even though it's wrong for them to charge it, and I'm astute enough to notice that they were charging it ... although I probably should have pulled out my insurance card on the spot and called my insurance company from the pharmacy. Most people in this area can barely afford their co-pay. They certainly can't afford to be ripped off. How many people is this guy ripping off?

:rant:

[triguy46]

1. they are in violation of the provider agreement with the....

pharmacy benefits administrator/clearinghouse used by your insurance company. In short, either they are in or out. They are acting as if they are out. They are not letting you have the meds for $10 because that is your co-pay. Call the insurance company back, have the Rx transferred to another pharmacy.

[AirmensMom]

7. Yep, I told him that.

And he said he didn't care. I am having my Rx transferred. But what is to keep him from ripping off other people? It's shameful that he's doing this.

He gave no warning of any kind that he wouldn't take my insurance card. Like I said, I've used this pharmacy for 3 years. But one of my friends called just today and asked if they submit to insurance and honor co-pays and they said of course they do. So they're liars as well as cheats.

[WolverineDG]

57. Is he a stand-alone pharmacist?

He's gonna start caring, when more people start going elsewhere. The only thing stand-alones have over the chains is service, which is why all the independent pharmacies in my town offer free delivery. If you think he's ripping people off, then talk to law enforcement.

dg

[CaliforniaPeggy]

2. He's probably ripping off lots of people...

People who are too tired, too preoccupied with losing their jobs and their so-called health insurance, to notice!

Damn.

Great rant!

K&R

:patriot:

[AirmensMom]

8. That's my thought.

And I'm very concerned about it. I really would like to put him out of business if this is the way he operates. I'm spreading the word as well as I can with my local friends.

[Kerrytravelers]

3. File a complaint with the BBB and call the State's AG office for the best person to contact

to file a complaint with the state.

[AirmensMom]

9. Thank you.

I hadn't thought of those options.

[mitchtv]

16. also file a grievance with the insco

They will end up dropping that pharmacy

[AirmensMom]

18. Did that.

We'll see what happens.

[gkhouston]

4. Does your city have a news channel with a "consumer advocate" reporter?

This sounds like a story for the "Channel X on your side" segment.

[AirmensMom]

10. Good idea!

I don't watch local news (being in the south ... bible belt ... Republican hell, etc.). But I will definitely see if there is some kind of consumer thing. They messed with the wrong person this time.

[Mudoria]

51. wtf are you on about? You're in the South so local news is freeper-ized?

[conscious evolution]

71. totally freeperized

You would have to live here and see it for yourself to believe it.
Even the so called liberal media outlets have a riech wing slant.

[valerief]

5. As many as he can, I'd guess. nt

[AirmensMom]

11. That's my fear. nt

[spanone]

6. i go to walgreens, co-pay $10. i go to kroger co-pay $4.

guess where i shop?

[AirmensMom]

13. Yes, but they won't order my Rx.

None of the national pharmacies will. So I found another local one that will. And they told me flat out that if my co-pay is $10, that's what I'll pay them. We'll see if they hold to it.

[timeforpeace]

21. What do you mean, none of the national pharmacies will order your Rx?

[AirmensMom]

23. That's what I mean.

I've called all over the place. They won't do it. Somehow it's not on their list or they don't get enough in ... lots of excuses why.

[timeforpeace]

25. That doesn't make sense. They can't "not order your Rx". Do you mean they don't take your insurance?

[AirmensMom]

31. No, I don't mean that.

I mean they won't order it. Whether it makes sense or not, they only order the hot sellers. I couldn't make this stuff up.

[timeforpeace]

35. You are making this stuff up.

[AirmensMom]

38. Right.

And the reason would be ...?

No, this is real. I have no interest in making things up. I don't care if you believe me. That's your problem, not mine.

[Kerrytravelers]

46. I have a very difficult to fill prescription, too.

The medication can not be found in the generic form. I actually do have to pay extra for it. And, it requires the pharmacy to do a bit of paperwork once a year for a renewal. I use to go to the local CVS. However, their pharmacists seemed too overwhelmed with the paperwork. My doctor took the prescription from them and gave it to a particular pharmacist who knows how to play the paperwork game. My medication was approved within 24 hours and I was on my way...


Also, my health insurance company changed the format for prescriptions, but neglected to notify us. So, I was waiting for a perception that was denied for paperwork reasons. The nonsense we go through for medication in this country is pure nonsense.

[WolverineDG]

59. I dunno, I've had some weird prescriptions & never had that problem at Target

Actually, I did have to wait a day because my doctor ordered my script in a weird dosage, so they had to order it.

dg

[WolverineDG]

58. That's why I use Target--get my scripts for $4 instead of the co-pay nt

[jberryhill]

12. How many people is this guy ripping off?

Lots.

This is the classic game played by everyone involved in the obscene "system" of health insurance we have. Deny payment... Overcharge... Deny coverage... and the suckers who don't have the time, determination or wherewithal to fight will pay.

[AirmensMom]

15. I'm a pain in the ass when I get ripped off.

They're about to find that out. ;)

You are so right, though. We have so much to fight these days and we have to choose our battles. In the grand scheme of things, this might not be a biggie. But it's still wrong and needs to be stopped.

[havocmom]

68. Besides the calls you made already: call advocates for the aged and the poor

Make DAMNED sure those who advocate for the least of us get the word on what this chap is doing so they can warn off their clients. Also look into any neighborhood activist types groups and give them a heads up.

Greedy, deal breaking people need to find out there are consequences for their actions. Make sure to find as many ways to make the point as possible.

Good on ya! We need to look out for more than just our own wallet. We need to look out for each other. The more of us who do, the faster change in primary values will happen.

[izzybeans]

14. So he just sold you a controlled substance for $15 and never reported it?

[AirmensMom]

17. Oooo ...

That's another problem, isn't it? And the insurance company knows about it so will include it in the complaint. Not like I think they'll actually do anything substantial ...

[izzybeans]

19. I suppose he did honor the prescription. I wonder if he handled that paper-

work properly. Seems odd.

[AirmensMom]

22. Well, it seems that he decided that if the Rx is too expensive,

he won't submit to the insurance company. As far as they know, it was never filled ... except that I told them today. So he's in when he wants to be and out when it costs too much. Never mind that I've gotten plenty of prescriptions from him that I'm sure he made lots of money from. It's just that this particular med apparently doesn't give him a big enough profit margin with the co-pay. So HE decides that he's not going to accept the co-pay, but just for the drugs that cost too much. Is that fucked up or what? I mean, why do I have a prescription card and participating pharmacies if they can still charge whatever they want?

[Statistical]

41. How does he get more from $15 cash vs $10 copay + $20-$80 from insurance company.

Something doesn't make any sense.

When you have a copay the insurance company pays the rest.

So instead of accepting a $10 copay + $x from insurance company he made you pay $15 + $0 from insurance company?

You said this is an expensive drug so he is selling it to you below cost for $15 and not charging the insurance company?

[AirmensMom]

43. I don't really understand why he didn't submit it to the insurance company.

I was surprised when they told me that. Perhaps he'll see his mistake at the end of the day, I don't know. If he then submits it, he'll get $15 from me and $x from the insurance company.

It's actually a tier 1 drug, so his statement that it's expensive doesn't make sense. Perhaps he means that it's expensive for a $10 co-pay.

[Ms. Toad]

45. That doesn't make sense.

If he is not submitting it to the insurance company for reimbursement, that means he is eating the extra cost (unless the extra cost is less than the extra $5.00 he charged). My daughter's meds, for example, cost about $4200 a month. If the pharmacist only charged me $15 ($5 more than I am supposed to be charged) but still gave me the $4200 worth of drugs it would be a losing proposition for the pharmacist, since the pharmacist is out of pocket far more than the extra $5 it collected from me.

Something is not adding up here - if the drug is as rare as you have indicated, the pharmacist would be far better off to eat the $5 extra you were charged than forfeit all but $15 of what it paid for the drugs in the first place.

[AirmensMom]

47. He's not eating any extra cost.

If he were, why is he worried about losing $3/month? (That's what he told me he'd lose.) I suspect that in his rush to over-charge me, he forgot to submit it.

I agree that something is not adding up. I'm just saying what happened. But I had forgotten how hostile DU can be when you tell the truth about something that happened.

[Ms. Toad]

50. If your prescription costs more than $15

and he is not being reimbursed by the insurance company there aren't many options other than that he is eating the cost.

It is hard to make helpful suggestions when something so obviously doesn't add up (not that you are not reporting what you know - but that there has to be something else going on that you may not know about and should look into.)

If the drug costs more than $15 and he submitted it for reimbursement to the insurance company, he is in breach of his contract with them - unless they changed the formulary, or he substituted a different brand that has a higher co-pay, or something else happened (like the pharmacy shifted to being a non-preferred pharmacy) that bumped your co-pay to a higher amount. Not all pharmacies accept all drug cards, and when they do not all charge the same co-pay. Mine only works at a handful, and some are preferred (a lower co-pay). Your pharmacist may have switched to a different status with the insurance company without telling you. If you don't get a reasonable explanation, file a complaint with the insurance company.

If the medication really only costs $15 a month, he may have dropped the contract with the insurance company and is charging you the actual cost of the drugs. Unfortunately I have had physicians who dropped the insurance company and didn't bother to tell me until it was almost too late to switch.

So - the elephant in the middle of this particular room is where is the pharmacist getting reimbursement for his excess out of pocket expenses if it is not coming from the insurance company. If economics is driving his charging a higher co-pay he has to be getting it from somewhere - and that somewhere may provide clues as to how you can resolve the issue.

As to why other pharmacies are not carrying the medication - a medication my daughter takes (incidentally at 8-12 pills a day) has gone through periodic shortages. When we have been unable to find it, it isn't because a pharmacy chose not to carry it, it is because the pharmacy couldn't get it. Check with support groups for people with the same condition you have and see if that may be the issue (and they may also know where to find it).

[Matariki]

52. AND some were missing out of the previous refill

might suspicious.

[hedgehog]

20. I go to an old fashioned owner-operated pharmacy. The owner lives three

doors down from me. He is very careful to ensure that his customers understand their medications. People will come in and ask him about this or that, and he will advice them to use an over the counter medication or suggest that they consult with a doctor. He will discuss whether a generic is a good option or not for a given medication. In other words, this guy is a pharmacist; not just a pill counter.

If you come in for a refill for a medication for a chronic condition and the doctor's office is closed, he'll give you the refill and have the doctor call it in later.

Now, my insurance company pays him less than his cost on one of my medications. I'm perfectly happy to pay him the difference because I know he is fair with his customers.

[AirmensMom]

27. This is a chain,

but a small one. Not sure how they operate. Going to the old fashioned owner-operated one next. They'll order my meds for me.

This guy isn't even a good pill counter. He shorted me 3 days worth of meds and tried to imply that I took them twice. Believe me, I would know if I took them twice!

It would be one thing if he told me what was going on, etc. But to simply sound like greed was his only motivation, whether or not I could afford to pay him more than my plan says I should pay, and to not turn it in to the insurance company, probably because he didn't want to get caught, gets my back up. And he was a real asshole on the phone. So he would lose $3/month on a med that only one other person in town gets from him. But he would make money on everything else. Well, sometimes it works that way. A good business will want to keep customers because they'll make more in the long run. He doesn't know it, but he lost 2 customers today (my husband and me) and at least 1 potential customer. I sure hope he thinks he got his $5 worth.

[timeforpeace]

32. In a chain, individuals do not make these decisions. You apparently don't understand what's

going on. My guess is, the copay that the insurance company pays the pharmacy in insufficient to cover even the cost of the drug to them. It is a loss, something that occurs quite frequently on Rx's these days. But $15 might let them break even on the cost of the drug, at least. In these circumstances, a pharmacy will be more than willing to fill the Rx for free, as long as their drug cost is covered. They do not bill the insurance company in this situation, that would be fraud.

By the way, what's the medication?

[AirmensMom]

36. Yeah, I understand what's going on.

They agree to accept a certain amount of money for prescriptions and then they charge extra when they don't like what the prescription costs. Only they don't tell the customer until it's time to pay that, oh, no, this time we won't use your insurance co-pay. He charged the correct co-pay until today. I've ordered this from him every month for 3 years. And I just talked with him on the phone this morning. Ya think he could've maybe mentioned that he was going to be charging more than my co-pay?

Not going to tell you what the medication is. Sorry.

[dysfunctional press]

24. if he doesn't report it to the insurance company, they won't pay him.

so- unless they only pay him $4 to begin with, then it doesn't make sense that he'd take $15, and not go thru the insurance company.

[AirmensMom]

28. All I know is that he didn't report it.

They said he usually does that the same day he fills it. (We matched it with other months.) :shrug:

[dysfunctional press]

67. he may do it at the end of the day, or something else...

but as i said- if he doesn't report it to the insurance company, they won't pay him- so unless $15 is the actual total price for the medication, it wouldn't make any sense.

[timeforpeace]

29. Correct. This whole thing does not make sense as reported. I suspect the pharmacist, who sounds like

the owner of the pharmacy as well, may want to lose you as a customer. If you can't get the Rx through a national chain, as you claim, then working with him has benefited you.

[AirmensMom]

33. Does not make sense as reported?

He has made plenty of money on other meds for both of us. What's this "as you claim" bullshit? Yes, there are some meds, which are less popular than the ones in print ads and tv commercials, that they won't order because they like to sell the popular ones. I used to get them from Wallgreens, until they "couldn't order it anymore."

[timeforpeace]

34. What is it?

[AirmensMom]

40. Oh, what, you're going to try to see if your pharmacy has it?

I don't have to prove to you that I'm telling the truth.

My, DU sure has changed ....

[musette_sf]

63. DU hasn't changed all that much

don't let someone who isn't a paying member, and with a goal of making 1K posts in 30 days, throw you off. :-)

[county worker]

26. I don't think you were ripped off.

Providers of medications and medical care contract with insurance companies. The contract stipulates the amount the insurance company will pay. It is optional for the provider to contract with any insurance company. If the provider doesn't feel his costs are being covered by the payment schedule he doesn't contract with the insurance company. The individual in that case pays what ever the insurance company doesn't pay.

In this case the insurance company paid nothing and the total cost was passed on to you.

That is why if you ever here about low cost medical insurance run away as fast as you can from it. Providers cost constantly go up but what insurance companies pay may not. A low cost insurance may not pay providers enough for them to want to contract with that insurance company.

I think that if there were a single payer system this problem would go away since insurance companies would be out of the picture and the payer would dictate the terms.


A public option would also help out because if enough people go with the public option the insurance companies would be forced to compete to stay alive. If a provider was forced to accept what the public option paid the insurance companies would pay the same amount or more.

[AirmensMom]

30. But he did contract with them.

And he represents to his customers that he accepts all co-pays. He didn't submit it to the insurance company. So for just this med, he's not a provider? No, the insurance company told me he has to let me have it for $10. I called them specifically to find out if this was a participating pharmacy and if there was any reason that I had to pay more than $10.

We have decent insurance through my husband's work. I have no idea if it's low-cost because they pay the premiums. I don't know how much they pay providers, but I know this: If you sign up to be a provider, you have to abide by the co-pay.

Here's what this pharmacist should have done:

1) Learned how to count so that he at least gave me 30 days worth of meds.
2) Told me when I called to refill my Rx that he is now charging more.
3) Submitted it to my insurance company, like he usually does.

I agree that it would all go away with single payer/public option. The question is whether we'll ever see such a thing.

[timeforpeace]

39. He has a bachelor's degree and a doctorate in pharmacy, as all pharmacists do.But can't count to 30?

Your continual charge of him not being able to count nullifies any credibility you have.

[AirmensMom]

42. Higher than that.

OK, you do the math. It's more than one per day. Let's say there are 8 per day. 8x30=240, right? It would be easy to lose count if you got distracted, which is probably what happened. Sometimes they flat out don't have enough and have to give me a "we owe you" note with a number saying how many they owe. OK, maybe they forgot to do that this time, but it was 3 days short.

I have a bachelor's degree too and I still make mistakes. Don't you?

[uppityperson]

48. Just because someone is able to count doesn't mean they do so correctly

Just because someone can read, and presumably pharmacists can, doesn't mean they always read correctly either. If they did, there would be a lot less med errors.



Just because someone has a username implying peace does not mean they are peaceful either. Having a name of uppity helps in the expectations others have of me though.

[Matariki]

53. what is your problem?

throughout this thread you've been implying the OP is a liar.

WHY?

Is it something personal, or do you enjoy starting flamewars or what?

[musette_sf]

64. see post 63

[conscious evolution]

72. Most pharmacists only have a masters degree

[guruoo]

56. DEA might want to examine his track record in regards to complaint #1

[mwooldri]

66. Single payer may not make this go away either.

The UK's NHS has a drug formulary - drugs that the NHS will pay for, and if it's not on the list, the NHS doesn't pay.

All insurance companies that cover prescription drugs have a formulary. Some stick to the list, if it's not on, it's not covered. Often insurance companies will cover drugs off the list after a medical review (usually a quick chat with the prescribing doctor, but sometimes can get detailed with pricey drugs).

But with the pharmacist, then yep it would appear the pharmacist is at fault. Pharmacist could have ran through the request, in theory could have lied to the customer and told the customer that the drug is not covered by the customers' insurance and the customer may well have paid that higher price and just taken it... if the customer calls the insurance and finds it was covered then the pharmacist has a mess to clean up.

Pharmacists of course are businesses. If the pharmacist has the issue over the price of the drug, i.e. it costs them more to purchase the drug than what they would get through re-imbursement either a) they need to speak to the insurance company and re-negotiate what they will get reimbursed for on that drug, or b) simply discontinue stocking that particular drug. There also is the situation that the pharmacist may well stock that drug as a "loss leader" - ie they may make a loss on selling that drug but gain on the sale of other stuff.

The OP is right to dump that pharmacy, and certainly can complain - definitely to the insurance company (who may well do something - I got charged a co-pay by a doctors' office, the office refused to let me see a doctor without paying even though I don't have a copay and I had met the deductible already... I complained to the insurance company and they sent me a check back... not the docs office, the insurance company did) and certainly BBB and state board.

Mark.

[MicaelS]

37. Check with your state Board of Pharmacy

Which cover licensing requirements in your state. See if you can file a complaint. Every state has one, PDF Document here: http://www.visalaw.com/IMG/pharmacistchart.pdf

[AirmensMom]

44. Thank you.

I will try that.

[Matariki]

54. Definitely - especially if your perscription was short

It might be a pattern for this pharmicist. Don't suppose your prescription was something that someone might want to take recreationally?

[gkhouston]

70. Very true. Any time I've ever been given a partial prescription, I've been told

it's a partial fill and that fact has been printed on the receipt. One pill off might be a miscount, although I doubt it. Three pills makes me wonder if the pharmacist is crooked.

[Ilsa]

49. Not all pharmacists are angels. Some of them get in trouble

for unethical practices, some of them get in trouble for drug abuse, just like other professionals.

[Phoebe Loosinhouse]

55. I have a larger theory and it has to do with the drugs themselves and the drug companies

I bet your drug is an older drug that is about to run out of its patent and that the pharmaceutical company has replaced it with a very similar, yet newer drug that changed one or two negligible aspects to the drug which allows a patent to be renewed or re-issued for the newer drug. You are probably in some window where the older drug is unavailable due to it's replacement and the generic is also not available yet, or is held up indefinitely due to the new patent.

Drug companies monitor prescriptions, drugstores and prescribing doctors like they are a Mafia protecting their turf. Why this oversight of an interested financial party in private drug prescriptions that should be ONLY between a doctor and a patient (unless in some special circumstance like a supervised trial) is allowed, tolerated, legal, I do not know.

My theory is just a theory, I am not involved in any way in the prescription drug industry, I just happen to read a lot. Obama had a bunch of stuff in his health program as a candidate that had to deal with bringing generics to market. Insiders know that this is a big problem that "America's Pharmaceutical Research Companies" as Montel Williams calls them, would probably rather not discuss.

EDIT******************
I was focused on the issue raised in post #13 and continued thru that subthread - why can't someone get a legitimate prescription filled? I wish I had posted correctly in that subthread.

[noamnety]

60. Did you count the number of pills they gave you today? (nt)

[mark olson]

61. Sound like the upcharged you for the days you were missing.

Are you sure you didn't get 33 pills in the new prescription. That has happened to me. Short pills and have to pay extra to get them so I am back on a regular 30 day routine. The pharmacy can't submit payment for them because they already got paid for 30 even though you maybe got 27 so they have to charge full price. Always count your pills.

[DainBramaged]

62. Target, no problems ever (but I have a shitty co-pay)

4 of the 7 drugs I take every month are generics at $4 each, the other(s) are $15, $25, and one is $50 co-pay (sliding scale). And they auto-refill and call when the refill is ready.

[mwooldri]

65. Does your insurance offer some kind of mail-order service?

If it's a non common maintenance drug, I find that Medco (my prescription drug plan administrators) can supply it through their mail order service. Express Scripts is another common larger name organization.

Too true that the large chains stock "the top sellers". I do deal with a local pharmacy, because we had to get an opiate for my son after a major surgical event. CVS, Walgreens, Rite Aid didn't stock it. The first CVS we went to told us 24 hours, went there 24 hours later and was told, sorry it's a schedule whatever controlled substance and it'll be 7 days before we'd get it in. They recommended this local pharmacist, and they were amazing. They had the drug but only in units double the prescribed dose. It worked out that the drug could be cut up, so the pharmacist then dispensed the appropriate amount of the higher-dosed drug (i.e. half the quantity) and we were all happy. As a result, that pharmacist has gained my business, especially if we get prescribed new unfamiliar drugs or more specialist drugs that otherwise would only be available at a hospital pharmacy.

[Horse with no Name]

69. They are under contract to honor the $10

and always count your pills. You'd be amazed at how many times they are wrong.