So how do pharmacies know what to charge each patient when they come to get their prescriptions filled? Well, despite the comments I’ve heard patients make over the years, the co-pay is not dependent on whether the pharmacist has a vacation coming up or if the pharmacist forgot his lunch and needs lunch money. The truth is, the pharmacy doesn’t know what the co-pay will be until the claim is processed to a Pharmacy Benefits Manager (PBM).
A PBM is a company hired by the insurance company to manage and administer the prescription benefits for your insurance company. Some examples of PBMs are Express Scripts, Medco, and CVSCaremark. The pharmacy submits the prescription information to the PBM and then receives an authorization or a rejection. When the claim is authorized, the amount of the co-payment is sent electronically to the pharmacy and is printed on the receipt. The co-pay generally will be the same at every pharmacy that accepts your insurance. Occasionally, if you have an insurance that pays a flat percentage of your prescription cost, there may be a small difference from pharmacy to pharmacy, as the amount submitted by the pharmacy to insurance may be slightly different.
If you ever have discrepancies regarding the amount of your co-pay, it is best to contact your insurance company. Your co-pay amount is determined by what is loaded into the PBM’s computer database by your insurance company. The pharmacy has no ability whatsoever to change an insurance co-pay, and it is not legal for the pharmacy to discount prescription co-pays.Leave a reply →