Prescriptions in the Hospital

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I have been having a lot of clients who have been in the hospital lately and are getting their standard $50-$100 bills for prescriptions. Do any of you have luck getting the Part D drug plan to reimburse them for this? The Hospital always tells them just send it to your drug plan and they will cover it. I've had a few try it over the years and haven't had any luck and when I call Humana or First Health or whoever they just tell me if it was a prescription from a pharmacy in their network have them submit the claim. The hospital refuses to submit it though.
 
1. When classified as "Under Observation", prescriptions are not covered. (Its important to distinguish between inpatient, outpatient and under observation)

2. The Part D plans WILL reimburse the clients-at the contracted rate. The pills that they pay Walmart $.50, the Part D plan will reimburse the patient $.50. Not the $5 per pill the hospital charged them. So yes, you can submit a claim. Just don't expect a lot of money from the Part D plan.

3. Let your clients know UPFRONT that when they go to the hospital, if they are classified as under observation, that the drugs aren't covered. They should be taking their prescriptions with them, in the original container from the pharmacy. (This isn't always practical, since under observation stays are typically via the ER, but at least it won't be your fault on the backend)

Hope this helps!
 
Even as an inpatient I see a lot of prescription charges that aren't covered.
 
What does "under observation" count as when on Medicare Advantage?

If you're "under observation" you're in outpatient status - so depending on the plan design, many plans require the customer to pay 20% of whatever happens in there. Part D drugs would be covered as dictated by their Part D plan.

If admitted as an "inpatient" then the hospital daily rate for the MA plan would apply.
 
I have NEVER been successful in getting reimbursed by a PDP carrier after an "outpatient" hospitalization. I get the runaround every time. Most of the time, my clients just give up and pay the $100 and chalk it up as a lesson. The other side of that, is that the hospitals in my neck of the woods have refused to let my clients take their regularly scheduled meds from home. It's a very frustrating situation.
 
I have NEVER been successful in getting reimbursed by a PDP carrier after an "outpatient" hospitalization. I get the runaround every time. Most of the time, my clients just give up and pay the $100 and chalk it up as a lesson. The other side of that, is that the hospitals in my neck of the woods have refused to let my clients take their regularly scheduled meds from home. It's a very frustrating situation.



recently my mother who is on medicare was IP and I asked the admissions and nurse on duty if they would use her existing scripts on hand and they said absolutely not.I believe it is a liability issue with them if they don't source the OP drugs for their patients. Just tell your clients that they will be responsible to pay for all OP drugs while IP whether they have pdp - and whether or not they have the original medicare or MA .
 
recently my mother who is on medicare was IP and I asked the admissions and nurse on duty if they would use her existing scripts on hand and they said absolutely not.I believe it is a liability issue with them if they don't source the OP drugs for their patients. Just tell your clients that they will be responsible to pay for all OP drugs while IP whether they have pdp - and whether or not they have the original medicare or MA .

It's liability and highway robbery. . .
 
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