Prescription Insurance

Prescription Insurance is an important part of your job as a pharmacy technician. You should know how to bill the companies responsible for prescription reimbursement.

You should know what to do when problems come up in the billing process. This means knowing what some common rejections are and how to go about overriding them.

You should also know what a co-payment and deductible are and how to decipher a prescription insurance card. It will also be advantageous to you to know how to explain these terms to your customers.

Rejections

No, we are not talking about being rejected by that guy or girl you've asked out for a date. Here we are talking about online billing prescription insurance rejections.

In a retail pharmacy setting, technicians who fill prescriptions often use online billing when submitting claims.

Online billing is fast-usually taking from a few seconds to a few minutes. Sometimes problems come up during the online billing process which prevent a customer's prescription from being filled when they want it to be.

The most common rejection that techs receive is a refill too soon rejection. Usually the company will give the earliest date at which the refill will be covered.

Another response could be a prior authorization rejection. This means that the customers prescription insurance coverage requires the doctor to contact them in order for them to pay for it.

Prescription Insurance Cards

When a new customer brings in a prescription to the pharmacy, there is an intake process. A pharmacy tech or aide will take down the full name of the patient, their date of birth, address, make a note of any medication allergies, and make a copy of their prescription card.

There are many insurance companies that you will become familiar with. Anthem, Medco, CVS Caremark, Cigna, Express Scripts, Medicare Part D and Medicaid are a handful of the insurances you may encounter in your work as a retail pharmacy technician.

Deciphering an prescription card is easy once you know how. All prescription cards contain a BIN number. This number is used to identify which company reimburses the pharmacy for the medication. Most pharmacies have a running list of BIN numbers which identify which company reimburses them for the cost of the medication. The acronym BIN stands for Bank Identification Number. It is a 5 digit number which tells the pharmacy’s computer where the claim should be sent. However, there are no longer any banks involved with the insurance billing process, so it can seem confusing. Apparently the term was carried over from the early days of electronic banking jargon.

All prescription cards also have an ID number. Most cards have a GROUP number as well. These are fairly self-explanatory

It is often necessary to know the name of the person who holds the policy and the person number of the insured. Usually the individual who is the primary accountholder has a person number of either "1" or "01" and the secondary is "2" or "02" and so on.

Co-payments

A co-payment is the patients’ responsibility. It is the part of the cost of the medication that the insurance does not pay for.

Many companies have prescription drugs in different tiers.

For example, generic medications could be in Tier 1 at a $10.00 co-payment. Brand-name medications which have a generic alternative could be in Tier 2 at a $25.00 co-payment. Specialty medications which are expensive and have no generic alternative available may be in Tier 3 at a $40.00 co-payment.

Deductibles

Many companies utilize a prescription deductible. This is in addition to normal co-payments. This means that for example, each year the customer is responsible for the first $100.00 towards the cost of his or her prescription medications. This would be an amount set by the prescription insurance company. This is in addition to their normal co-payments. Basically, a deductible is the amount of the patients financial responsibility before their coverage begins.

Pharmacy Benefit Managers (PBM's)

When you or the pharmacist sends a claim online, the transmitted claim does not go directly to your insurance company. It goes off to a Pharmacy Benefit Manager (PBM), a company that makes its money by only handling the billing for prescriptions. It may be a different part of the customers current insurance company, or it may be its own company, its own entity, like Express Scripts or Medco. There are different BIN’s for each PMB. If the company the customer works for changes PBM’s, things can get more confusing. Their employer may have contracted with the new PBM and agreed to maintain the same benefits, but everything may not be the same when sending the claim online for billing. The pharmacy may have a difficult time billing the claim without the prescription card (or at minimum, the new ID, group and BIN numbers.)

Top of Prescription Insurance Page

Back to Home Page