Reimbursement Problem with CVS

[dtwarren1942]

My claim for My Trimix reimbursement under my CVSCaremark prescription plan was declined and I was requested to have the compounding pharmacy provide pricing for each of the individual ingredients. Has anyone come across this problem. The compounding pharmacy, Wedgewood, advised that they buy in bulk and it will be difficult to reduce the cost to individual prescriptions. I questioned CVS if they could provide me with the name of a pharmacy currently providing individual ingredient costing and was advised by the rep that she could not come up with any names. Does anyone work with a pharmacy that provides individual costing? Or can anybody provide names and tel no of their compounding pharmacy so I can call and inquire if they can comply with the CVS requirement.

[drobert14]

I also have a CVSCaremark prescription plan and have not experienced any issues with past claims. I just sent a claim in the last few days so we'll see if I run into similar issues. Usually the pharmacy gives me a universal claim form with the pharmacist’s signature and I complete that form as well as the CVSCaremark form. The CVSCaremark form has a place to indicate the individual ingredients, and I just write in, "see attached universal claim form".

I currently use Francks Compounding Pharmacy in Ocala FL and previously used American Pharmacy Solutions (APS) in Pensacola FL. APS transferred my prescription to Franck's Pharmacy last year because for some reason they lost privileges to fulfill a prescription in Tennessee. The only issue I had with CVS so far is that I fulfilled my very first prescription at a pharmacy here in Nashville and it was applied to my "out-of-network" deductible. I had to call CVS Caremark customer care to find out what compounding pharmacies are considered "in-network" and then have the Urologist office send a new prescription.

CVS Caremark does not cover the shipping cost and if I remember correctly they reimbursed about $44 on a bill of about $108 (including overnight shipping).

Of course, prescription plans vary in coverage, even within the same provider, depending on the group plan you are associated with.

[dtwarren1942]

Thanks, drobert. Last year CVSCAREMARK reimbursed me for 100% for two prescriptions. I was told today by a rep that they changed their policy for 2012 and now require the ingredient costing. She further claimed that a federal law requires compounding pharmacies to provide this information. She further advised that if my pharmacy is unable to provide the detailed information , Caremark will report them to the FDA to be sanctioned.

Please advise the response to your claim request.

[Spartan]

I am aware that my Rx insurance carrier (Medco) will only allow the cost of ingredients for compounded scripts to participating pharmacies. Two 2 mL vials of Trimix cost me $8.45 per Medco rules. That was the total cost (the plan paid nothing) per their agreement. Somehow the pharmacy had to come up with the cost of ingredients to set the price. Their communication and pricing was done by the computer submission to Medco.

That doesn't help your situation with CVS, but may explain why CVS wants the actual cost of ingredients. They may only be willing to pay for the ingredients.

[drobert14]

Thanks, drobert. Last year CVSCAREMARK reimbursed me for 100% for two prescriptions. I was told today by a rep that they changed their policy for 2012 and now require the ingredient costing. She further claimed that a federal law requires compounding pharmacies to provide this information. She further advised that if my pharmacy is unable to provide the detailed information , Caremark will report them to the FDA to be sanctioned.

Please advise the response to your claim request.

Well I had the same issue. CVSCAREMARK returned my claim for more info, "....cost for each individual ingredient". I had used Franck's Pharmacy, http://www.francks.com/, so called them and they are sending me a new Universal claim form with the ingredient cost.

Furthermore, they can file directly with CVSCAREMARK rather than me having to fill out paper forms. So for future prescriptions I just need to let them know I have CVSCAREMARK and they'll take care of submitting the claim.

Their cost for 5ML TRIMIX 30MG/1MG/10MCG is $90 and overnight shipping is $24.95 for a total of $114.95. If my memory is correct I believe I was reimbursed $44 the last time I filed a claim.

So that's a net cost of $70.95, but we'll see if the reimbursement changes under the new filing requirements.

[dtwarren1942]

Got back a response from my compounding pharmacy (Wedgewood) advising that the ingredient cost of Trimix is only a fraction of the total compounding cost and that if they revealed the ingredient cost, it would more than likely be below any co payment required by my insurer. They went on to advise that the larger portion of the cost is due to the team of specialized pharmacists, and pharmacy technitions working in a state-of-art laboratory. In addition, other costs such as quality control and accreditations, preparation testing, customer care specialists, pharmacy training and licensing, equipment, clean room facilities, refrigeration, packaging, and shipping operations are also included in the cost of preparing high quality compounding services.

I guess I will need to absorb the $72.50 per 5 ml vial of Trimix if CVSCaremark is unwilling to accept their explanation.

[drobert14]

I obtained the revised Universal Claim Form from my pharmacy (FRANCK's Compounding Pharmacy) and re-submitted to CVS/CareMark but that was rejected as the pharmacy had added all the ingredients including sterile water, etc with some elements at $0.00 for cost. The paperwork was sent back to me with every $0.00 amount circled.

I called the pharmacy and had them submit directly to CVS/CareMark (they were more than willing to help), however the re-imbursement was only $39.

So, their cost for 5ML TRIMIX 30MG/1MG/10MCG is $90 and overnight shipping is $24.95 for a total of $114.95 less CVS/Caremark reimbursement of $39 = net cost of $75.95

But I have in the past used a local compounding pharmacy and their cost was $105 and CVS/Caremark considered them an "out-of-network" pharmacy and the amount was applied to my "out-of-network" deductible (which is higher than I have ever spent in one year on all medical costs combined) so I was out the entire cost.

[dtwarren1942]

So, their cost for 5ML TRIMIX 30MG/1MG/10MCG is $90 and overnight shipping is $24.95 for a total of $114.95 less CVS/Caremark reimbursement of $39 = net cost of $75.95
.

Thanks for the info. My pharmacy charges $72.50 plus $10 shipping so my cost will be $82.50. I use about 12 units per injection so the 5 ml vial will provide me with a little over 40 injections or about $2 an injection. Actually, not a bad deal. Much cheaper than prescription meds even after insurance coverage.

Interesting to note that when I discussed the costing issue with two representatives at Caremark on separate occasions, each mentioned that federal regulations require pharmacies to provide costing information. However, when I called the FDA, I was advised that the FDA was not aware of any such legislation.

[katsboytoy]

one more reason to stay clear, my conpary left them a few years ago.