I have seen a lot in my years as a pharmacy owner. And while I often discuss the sometimes questionable tactics of prescription drug plans, sometimes I encounter something so disheartening that it gives me pause. So starts this episode of Tales from the Counter.
Several times now, I have had patients question an increase in their copay upon picking up their prescription. One patient noted that their first fill cost her a $23.54 copay while this second refill returned a copay of $71.02. The patient is often surprised to find that the pharmacy rarely dictates the price of the prescription: pharmacies are contractually bound to accept the authorized amount the payer returns. Because of this, I have to refer the patient to their prescription drug plan for any questions about copays.
One consequence a plan’s contract with pharmacies is that the plan can rein in costs. The plan generally will set a generic drug’s reimbursement price to reflect the least expensive product available. This is reasonable, as not all generic products cost the same. And pharmacies work hard to purchase a product that prevents them from losing money. The result: pharmacies must periodically change manufacturers for any given generic product based entirely on the purchase price. Ironically, in almost every case we see of disputed copays, the discrepancy is related to a change in the manufacturer of the product that we dispensed.
Let’s look at what is going on with a concrete example from a recent patient. Here, between Claim 1 and Claim 2, we changed to a different product (identified by a different National Drug Code or NDC) based on a cost difference to us of about $0.01 per capsule when contracts changed. You might be wondering why we would change manufacturers over a penny per capsule. In the case of our prescription below, $0.01/capsule differential equates to a $1.80 difference in our cost to dispense. That represents almost a 14% difference based on the plan’s $12.99 allowable reimbursement.
Let us take a close look at both claims side by side. Theoretically, the plan would treat both generic manufacturers the same and the allowed price and the patient copay would not change.
| Claim 1 | Claim 2 | |
| Product (NDC) | A | B |
| Qty | 180 | 180 |
| PBM Authorized $ | $12.99 | $80.20 |
| PBM returned Patient Copay $ | $12.99 | $60.00 |
This is obviously not the case, as the second claim was paid at a much higher rate and the patient’s copay was significantly higher as well. In the case of Claim 1, the prescription drug plan appears to have used a different price schedule than in Claim 2.
It is very disappointing when a prescription drug plan blames the pharmacy for this type of situation, and I have been disappointed several times, with one specific plan regularly and unfairly shifting blame to the pharmacy. The general solution that a plan gives the pharmacy is for the pharmacy to use a different manufacturer’s product (NDC) so the patient will get the correct copay. This leaves me flummoxed. Shouldn’t the plan instead simply correct their price schedules so that the claim processes correctly?
At times I wonder who is actually running my pharmacy. Prescription drug plans tell me what I will get paid. By doing this, they force me to purchase the least expensive products. Now, they are telling me to use a more expensive manufacturer’s product so that our mutual patient will get the best price? This puts the pharmacy in a difficult situation. The plan is quick to tell the patient that if your pharmacy doesn’t use the specific manufacturer’s version of the medication to go to another pharmacy that will, maybe even the plan’s own mail order pharmacy.
Ironically, up to this point, the problem has only manifested with one specific Medicare Prescription Drug Plan. And each time, the plan’s customer service representatives do not mention the patient’s other choice: choose a different Medicare Part D plan.
When faced with challenges like this, it is important for the pharmacist or pharmacy owner to intervene. Work the problem and be sure the patient understands all of their options. Work to overcome the inane obstacles being thrown at the pharmacist, and above all else, Make Every Encounter Count.