Some Important Information about Insurance!
It is becoming increasingly rare for insurances companies to pay for compounded prescriptions, especially in California. Here is the reason why:
Compounded prescriptions are not the same as prescriptions you pick up from your regular pharmacy. Insurance reimbursement is based on a universally recognized National Drug Code (NDC) number. All drug manufacturers are required to register and list their drug products with the Food and Drug Administration. The product is then assigned a single NDC number. This 11-digit number identifies the manufacturer, the name of the product, and the package size. The number is unique for every drug product. When a pharmacist dispenses a regular prescription, the insurance company pays the pharmacy a dispensing fee over and above the cost of the drug based on that single NDC number. For regular prescriptions, claim submission is done electronically. The pharmacy enters the patient information into their computer, along with the drug’s NDC number and quantity to be dispensed. Within moments the pharmacy receives an electronic confirmation that the claim is either paid or rejected.
Compounded prescriptions are different. Compounded prescriptions are customized blends and formulations that may have several active ingredients and maybe a half-dozen or more inactive ingredients. Sometimes the “inactive” ingredients are just as expensive as the active ingredients. Because we use only FDA approved ingredients, every individual ingredient used in the formula has a separate NDC number. Current electronic claim standards only allow the submission of a single NDC number for the entire prescription. If we make a product that contains ten ingredients and the insurance company only reimburses us based on one ingredient, who pays for the other nine ingredients? Compounded prescriptions containing multiple ingredients, with multiple NDC numbers cannot easily be billed electronically, and most insurance companies are not capable of processing electronic claims for compounded medications.
However, some insurance companies still allow for the submission of a paper claim. Paper claims are typically not limited to single NDC numbers. Paper claims are not processed electronically – they are actually reviewed by a real person at the insurance company who can see a list of all the ingredients and then determine the appropriate amount of reimbursement. To simplify the process for you, Apothecary Options provides you with a completed universal claim form with every prescription (the claim form is stapled to the back of the drug information sheet). This form includes all the information you need to submit a claim directly to your insurance company for reimbursement.
One final word — When a pharmacy signs a participation agreement with an insurance company, the pharmacy agrees to accept whatever reimbursement the insurance company is offering, for the range of services the pharmacy normally provides. Note: Many pharmacies do not offering compounding services and so this section does not apply to them. However, if a pharmacy routinely dispenses both compounded and regular prescriptions, it is usually unlawful under most contracts for that pharmacy to accept your insurance and co-pays for your regular prescriptions, but then turn around and refuse your insurance and charge you an out-of-pocket price for a compounded prescription. The pharmacy is not allowed to pick and choose which part of the participation agreement they intend to honor. If this is happening to you, call your insurance company and speak with a pharmacy benefits manager. They can help you determine if the pharmacy in question is violating the terms of their contract.
We are committed to providing our clients with products of uncompromising quality at very competitive prices. Because we don’t accept or bill insurance companies, our staff doesn’t have to spend valuable time and resources tracking down and resubmitting unpaid claims. This cost-savings is passed directly to you as a lower out-of-pocket price. If you live in California and would like a price quote, please give us a call.
Thank you again for choosing Apothecary Options!