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Calprof54

Pharmacy refuses to fill prescribed generic

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Hello, Mark -

My dr. Has prescribed generic carbidopa/levodopa from Sun Pharma because this one doesn’t make me nauseous like Actavis pills do. The online pharmacy I’m required to use by my employer refuses to fill the Sun Rx, stating that they are a huge company and they make deals with whichever manufacturer provides the best (as in cheapest, I think) deal.  They said I can go through my local Walgreen’s, but the cost will be over $200 - well beyond the $10 copay if I stick with the online pharmacy.

Any suggestions on ways I could appeal the online pharmacy decision or other steps I can take?  Thanks for your time and expertise!

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Calprof,

I have not seen much success with converting the online pharmacies to try a different generic medication. It is true, they buy in such large quantities from the manufacturer that will give them the best price.

I usually recommend that you try one of your local pharmacies (Costco, Walmart, Sam's Club, etc..) and use the Good Rx discount card. You can pull this up as an app on your phone and it does give great discounts on thousands of generic medications. I don't know of a retail pharmacy that does not accept it.

I hope this helps and please keep me posted.

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 If you get an antibiotic at retail, for an infection, how are you reimbursed by your insurance? 

If I go to retail, my insurance applies the cost of retail medication to my deductible and/or coinsurance exactly as if it were a doctors office charges, or lab studies.  So, I can get whatever I want at retail and the insurance company can't tell me no.  And, ultimately the plan sponsor can make an exception to cover whatever they want.

 

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Waywrd,

Reimbursements vary from insurance company to insurance company. The normal billing practice is that insurance companies will pay AWP (Actual Wholesale Price) plus a small fee, let's say $1.25. If the cost of the medication is less than your copay, you will be charged the lesser of the two.

Many pharmacies now have a $4.00 generic program which covers a large number of generic medications. Contrary to popular belief, the pharmacies themselves do not make very much money per prescription, that is why quantity of prescriptions is very important. There are certain circumstances and opportunities can make money of inexpensive generics where they can buy in bulk. The truth is that the pharmacies can make more on no insurance prescriptions, but as much as 95% or greater of prescriptions are covered my insurance.

I hope this helps and please keep me posted.

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My employer will allow a temporary (i.e., one-time) prescription filled through my local pharmacy. But if it is going to be a long-term medication, they want me to use the online pharmacy service.  Good news - I contacted my employer and told them about the online pharmacy's refusal to fill the manufacturer-specific generic I need. They got right on it and set up an agreement with the local pharmacy to fill the Rx on a long-term basis.  I'm glad I pursued it - it was mostly a matter of finding the right person to talk to!

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Calprof,

This is a little trick that very few employers tell you about. Since many of the mail order companies are set up to purchase a medication at the cheapest price possible, may times this does not work for certain medications such as Parkinson medications, blood thinners, and certain seizure medications.

Thank you so much for the information and if you have any other questions, please keep me posted. 

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