Inconsistent requirements from insurers producing fear in pharmacists

A couple of insurance companies told Lange they may ask for additional documentation to process test kit reimbursements in the future. He fears such requirements by insurers and their pharmacy benefit managers (PBMS) — third-party administrators health plans use to manage prescription drug benefits programs — will stymie his payment or pay less than what he spends to get tests.

PBMS negotiate insurance claims and manage pharmacy networks. They secure discounts for drugmakers and turn a profit by up-charging drugs or keeping rebates.

“That’s the problem with managed care,” he said. “Later on down the line, they’re going to come up with something that will preclude them from paying us.”

Steve Moore, a board member for the Pharmacists Society of the State of New York, expressed similar doubt about insurers. Moore called the reimbursement process “inconsistent at best” considering insurers’ requirements thus far have varied from one to the next.

He offered Express Scripts as an example. Its policy makes pharmacies responsible for ensuring purchased tests aren’t used for work purposes, according to Moore.

There are also issues with Medicaid and Medicare, observers say. Traditional Medicare plans will not cover or reimburse tests bought at retail locations or pharmacies, meaning those members will have to seek test kits elsewhere, likely through government channels. And Medicaid currently requires those looking to buy a test kit from a pharmacy to have what they call a fiscal order, which is essentially a written or electronic prescription.

Moore said a Medicaid representative called him Wednesday to notify him the fiscal order requirement will soon be removed. The decision has not been finalized and won’t immediately go into effect.

Until then, the fiscal order adds a “potentially significant amount of work” to pharmacy staff ’s duties, Moore noted. Like Lange, he anticipates PBMS will be an issue.

“There will be issues with callbacks and all the other games that the PBMS like to play,” he said. “These companies will try to do everything they can to make this as hard as possible.”

Moran doesn’t expect added requirements should be a concern.

“The rules are pretty clear,” she said. “Plans must cover it.”