Email String Exposes Rx Prices and Schemes


Someone sent us an email string yesterday regarding an insured’s attempt to get a prescription filled. Apparently the patient was told by the pharmacy that his prescription was not going to be honored by the pharmacy benefit manager. Of course, the patient was not too happy and complained to HR:

INSURED: Elizabeth, the pharmacy is calling me that the medication Matthew is needing is not covered by the insurance? There are two medications (1). Levofloxacin 100 mg  (2). Mometasone 0.6 mg. He would need a 30 day supply can you check on this for me?

ELIZABETH to PBM: Do you show anything in the system for XXXXXXX for these meds?

PBM TO ELIZABETH: I just wanted to let you that we received a fax early this morning. Our clinical department is reviewing the information, and we should have a determination shortly.

PBM TO ELIZABETH: We had one of our clinical pharmacists talk to the pharmacist at XXXX Family Pharmacy. We wanted to see if the pharmacist would submit a lower price for the medication, he is submitting a cost of $1,600+ when in reality the medication should only cost around $40…..but he would not. The main ingredient in this compound is usually around $5 per gram. The pharmacy is trying to charge $120 per gram on an expired NDC code (all drugs have NDC codes for claim processing). Because of this inflated charge, the pharmacist may say that we will not cover the compound. This is not the case. The compound is covered, but should only cost around $40. At this point we would normally suggest the doctor be called to try an alternative commercially available systemic antibiotic.

PBM TO ELIZABETH: XXXXXX Family Pharmacy is attempting to charge $1,579.97 on a compound for Levofloxacin powder. According to prices we have on all the ingredients being submitted, the total cost should only be around $40. Please advise if the plan wishes to override the cost for this member and allow the pharmacy to bill for the full amount.

ELIZABETH TO PBM: How is this applied? What are the directions?

PBM TO ELIZABETH: I’m sorry Elizabeth, but those questions will need to be directed to the member, or pharmacy. These are not options that are supplied on an adjudicated claim. The only fields provided are ingredient, quantity, day supply, and cost. Also, I tried to call the pharmacy earlier to obtain the ingredients, and they would not give them to me, as I am not the doctor, nor the member. Of course, little did he know I can see the ingredients, I just wanted to verify.

PBM TO ELIZABETH: Sorry, I had to have one of the pharmacists obtain the additional ingredients. Please see the ingredients, qty and cost being submitted by XXXXX Family Pharmacy:  Levofloxacin Powder – 6.o quantity, $726, Mometasone Powder, 0.033 quantity, $6.17, Loxasperse Powder Base – 7.32 quantity, $841.80.

Editor’s Note: Between the email above and the one below, Elizabeth found another local pharmacy with more reasonable pricing

ELIZABETH TO PBM: Have you seen a claim come through? What was the final price on it and how much does the employee have to pay?

PBM TO ELIZABETH: Yes, the claim did pay. The group is being billed $63.57 and the member is paying $25. I guess the pharmacy was finally able to locate a cheaper NDC.

This story has a happy ending. One pharmacy was going to bill about $1,600 while another charged less than $100 for the same prescription.