|
Editor's Note: Due to the seriousness of the discriminatory practices of the PBMs, the following is a note received from a pharmacist that describes his recent experience.
"I thought I would share with you an exchange I had with Medco over a compound we were given on Friday. As has been the case with most all Express-Scripts related claims, submission for a formula including several bulk powders was denied.
I decided to try a formula using generic Solaraze (Diclofenac sodium 3%) as the primary analgesic ingredient, and two other commercial products were included as well as a bit of a penetrating liposomal base to QS to final weight. Starting with Voltaren gel would be a waste of time.
This formula was ultimately approved for payment ($877.74 total reimbursement, with a patient co-pay of $345.12). Since the co-pay was a somewhat odd amount, I decided to call and ask for clarification of the patient's responsibility—was it a percentage co-pay, a deductible, or some combination? The customer-service agent explained that the patient is responsible for "20%." I asked for further clarification since $345 is hardly 20% of $877. She said the client is charged $1380.50, which means Medco added an up-charge of over $500 to the plan sponsor for simply adjudicating the claim. I explained that even at that figure $345 is still more than 20%. She finally stated that because the usual and customary amount (we bill at full AWP plus $10) was $1740 the patient was responsible for 20% of that number. Incredulous! I thanked her for her thorough explanation and ended the call. She probably said more than she should have. I subsequently reversed the claim and just for grins sent a test claim for plain Solaraze 100 g. That claim rendered $753 to the pharmacy and a co-pay of $189. Usual and customary was $1189.46 (that is AWP plus $10). Not sure how the 20% co-pay figures in on this one though. It would be 16% of usual and customary and 25% of total amount paid. At 20% the total claim would be somewhere around $945 to the client meaning Medco's take was around $200 for a purely electronic claim—no human intervention necessary.
Since the initial claim included 120 g of the Solaraze generic, I would extrapolate a purely generic ingredient claim to render about $945 for the sole ingredient. This means by indicating a compound was to be made, we would have been paid $70 LESS for our time, effort, and the additional ingredients.
It makes one wonder though why they are refusing to pay claims for compounds when they are padding the bill by $500 or more on some occasions. Could it be the client calling for greater transparency?
At least now we know how the CEO can take a salary as large as he does."
Loyd V. Allen, Jr., PhD, RPh
Editor-in-Chief
International Journal of Pharmaceutical Compounding
Remington: The Science and Practice of Pharmacy Twenty-second edition
|
|
News
U.S. Generic Drug Prices Soaring
Fewer companies in the generic drug market lead to companies driving up the cost of some generic drugs; this is prompting U.S. investigations into the pricing of what should be cheap alternatives to brand-name medications. As an example, doxycycline has increased from 6.3 cents to $3.36 each. Also, clomipramine has increased from 22 cents to $8.32 each. It is taken for granted that generic drugs are low-cost, but they're only low-cost because there's competition. When that competition disappears, the prices increase. Because of these increases, both the U.S. Senate and the U.S. Department of Justice have undertaken investigations into generic drug pricing.
http://consumer.healthday.com/general-health-information-16/misc-drugs-news-218/u-s-prices-soaring-for-some-generic-drugs-experts-say-693679.html
Immigration Causes Medicaid Enrollment Spike, Report Shows
Legal immigrants, "unable to support themselves and their children," are responsible for nearly half of the new Medicaid enrollments from 2011 to 2016, said Steven A. Camarota, research director at the Center for Immigration Studies. Nearly half the growth of Medicaid enrollment from 2011 to 2013 was due to immigration, according to a new study being released Thursday that argues the generous U.S. immigration system is straining the federal safety net. Immigrants and their children made up 42% of Medicaid enrollment growth during that period, even though they were only 23% of the overall population growth in the U.S.
http://www.washingtontimes.com/news/2014/nov/13/immigration-causes-medicaid-enrollment-spike-repor/
HHS Chief Burwell Promotes Extending Obamacare Benefits to Illegal Immigrants
Burwell was touting the upcoming Obamacare enrollment period and advocating for a change in immigration policy. Currently, only legal immigrants are eligible for Obamacare benefits, but pro-immigration groups have advocated that Obamacare benefits should be extended to illegal immigrants.
http://dailycaller.com/2014/11/11/burwell-we-need-to-give-obamacare-to-dreamers/
Physicians Cashing in on Drug Tests for Seniors and Medicare Pays
Physician pain specialists are ordering expensive tests for illegal drugs, such as cocaine and angel dust, which few seniors ever use, and Medicare has to pay the bill. Currently, medical guidelines encourage physicians who treat pain to test their patients, to confirm they are neither abusing them nor failing to take them or, possibly to sell them.
This has resulted in some pain specialists making more from testing than from treating. One physician stated, "Urine drug testing is how I pay the bills," having received $1.4 million for drug tests on his own patients.
$445 million was spent by Medicare on 22 high-tech tests for drugs of abuse in 2012, up 1,423% in five years. Testing for PCP (angel dust) hit $14 million that year and a laboratory director in Georgia said she has never seen someone over 65 test positive for angel dust in 25 years in the business. Even though laboratories perform most drug tests, there are ways doctors themselves can be reimbursed, including by doing the tests right in their offices. One laboratory was paid an average of $1,265 per Medicare patient in 2012.
http://online.wsj.com/articles/doctors-cash-in-on-drug-tests-for-seniors-and-medicare-pays-the-bill-1415676782?cb=logged0.2168474494720603
|
|
ACHC is pleased to announce that the following pharmacies have achieved PCAB Accreditation:
Tech-Pharmaceuticals, Inc., dba Vidascript, Miami, Florida; Mario S. Cuervo, mcuervo@vidascript.com. Initial Accreditation for Nonsterile Compounding
Medical Center Pharmacy Inc., Cleveland, Tennessee; Donald Ahlberg, PharmD, dahlberg@medicalcenterrx.com. Re-accreditation for Sterile & Nonsterile Compounding
Chemistry Rx, Philadelphia, Pennsylvania; Amany Mansour-Awad, ama@chemistryrx.com. Initial Accreditation for Nonsterile Compounding
Central Iowa Compounding, Urbandale, Iowa; Sue Horton, RPh, centraliacmpd@msn.com. Re-accreditation for Sterile & Nonsterile Compounding
Bay Pharmacy, Eustis, Florida; Gordon Punt, baycompounding@earthlink.net. Initial Accreditation for Sterile & Nonsterile Compounding
Brown's Compounding Center, Englewood, Colorado; Audra Olson, PharmD, audra.olson@brownscompounding.com. Initial Accreditation for Sterile & Nonsterile Compounding
Custom Rx Pharmacy & Wellness Concepts, Wichita, Kansas; Jan Gerber, RPh, jgerber@customrx.net. Re-Accreditation for Nonsterile Compounding
Central Compounding Center South, Durham, North Carolina; Jonathan Pritchett, PharmD. customrx@gmail.com. Re-Accreditation for Sterile and Nonsterile Compounding
Yee's Pharmacy, Long Beach, California; Steve Yee, PharmD, yeesrx@verizon.net. Re-Accreditation for Nonsterile Compounding
Potter's House Apothecary, Peoria, Arizona; Kevin Borg, PharmD. kevin@pottershouserx.com. Re-Accreditation for Sterile and Nonsterile Compounding
MedQuest Pharmacy, North Salt Lake, Utah; Kyle Anderson, kanderson@mqrx.com. Re-Accreditation for Sterile and Nonsterile Compounding
Medi-Drug Inc., dba The Medicine Shoppe, New Port Richey, Florida; Divyesh Patel, DP@medidruginc.com. Initial Accreditation for Nonsterile Compounding
|
