View Full Version : Pharmacy won't let me pay cash for Rx that insurance won't cover.


thaney
04-27-17, 09:58 PM
I'm in my second month of Adderal. It's helping, and I've got two supportive doctors behind me. (I'm very thankful; this is so many years overdue, but at least I'm finally getting on track!)


I went to CVS to fill it. My insurance doesn't cover it (doc went back and forth with insurance for weeks to no avail,) so I paid by cash last month. Not ideal, but fine, whatever. This month, though, they informed me that since my insurance company opted to not pay for it, that I was not allowed to pay cash for it, either.

The pharmacist also mentioned that though this was the law/regulation, that I might have better luck at a different pharmacy. That's what I did, and was able to get my Rx filled elsewhere. That is super for this month, but I don't want to worry every month that I will be told I cannot have my prescription.

Insurance companies already play God by not paying up for medications, but since when did they get to tell me that the prescription that was written by my doctor (you know, that fellow who attended medical school) was something I couldn't fill? I'm not asking them to pay. It should be my doctor's job to be sure that I am using my medication appropriately (I am) and to make decisions about what I receive. Why does my insurance company, whom I am not even asking to pay for any of this, get to tell me I cannot pay my own cash for my own prescription?

I'm in PA in the USA, by the way. Has anyone else encountered this? I understand being careful about these kinds of drugs--absolutely--I understand how easily abused they are. But they exist for a reason.

namazu
04-27-17, 10:06 PM
I've never heard of such a "law". What do they do for people who lack insurance/prescription coverage altogether?!

As long as you have a valid prescription, there's no reason for them to deny you the medication on the grounds that your insurance company is being a pain. Your insurance company, as you note, can refuse to pay, but they have no right to veto your treatment and overrule your doctor.

If this particular CVS had labeled you a "drug seeker" for some reason, they'd be within rights to refuse to fill your prescription. But having a problem with insurance doesn't seem like a valid reason to assume you're up to no good.

I wonder if a phonecall or certified mail letter to the PA manager for CVS would do any good.

How frustrating!

thaney
04-27-17, 10:35 PM
So I told my pastor (who keeps well-informed about... everything) about it tonight and she wasn't even a little surprised. She says that insurance companies are greedy and that (like I said) it makes sense to control this sort of substance to a point, this is not the appropriate way to do so. But (unlike me) my pastor seemed well-aware that this was a federal regulation.

In googling for this, I could not find anyone else who has had the experience, and The People Of The Internet do seem to have a lot to say on ADD meds, so I'm even more surprised it never came up.

My current insurance is through the state (so... Medicaid). The pharmacist said that they are not allowed to allow Medicaid patients to pay by cash because the state believes they "shouldn't" have the cash. (And really, I don't have the cash; it's a huge struggle even to pay for this med!) Since they shouldn't have the cash, it was explained to me, it is highly likely that they are selling or abusing the medication if they are getting it anyway.

If I was to go to a different pharmacy and not give them insurance information, would I have avoided this whole problem? That was what I was going to try next, if I wasn't able to get it filled where I got it filled.


This whole thing is ridiculous.

Luvmybully
04-28-17, 01:27 AM
WOW. This is shocking to me. You can not provide yourself with the Rx your Dr prescribed you??

This is wrong on so many levels.

dvdnvwls
04-28-17, 02:31 AM
Does the pharmacy do this because if you do pay cash then your insurance company is within their rights to kick you off your plan?

sarahsweets
04-28-17, 06:00 AM
Its not an insurance thing imo, its a suspicious CVS thing. The insurance company has no say on something they are not paying for.

thaney
04-28-17, 10:15 AM
Wow, or apparently it's a Medicaid thing? I googled for that and it seems to be the norm: if you are on Medicaid, you are not allowed to pay for anything yourself.

And that makes some sense; if you're on medicaid, you probably can't be affording much in the way of medical care. However, if Medicaid declines to pay, what's one to do?

I can tell you that I skimped on necessities last month to cover my prescription, and a friend helped me pay for it this month. None of that is ideal.

...but this medication seems to really be helping. If I want to turn things around (and ultimately NOT be dependent on the state for anything), gosh darn it, give me the thing that helps!

I avoided meds for a really long time, but you know what? They help.

sarahsweets
04-28-17, 12:13 PM
There is no way that this can be true:
Here are some responses I found:
Pharmacies sell drugs after the MD has given permission to them to sell it to the patient in the form of a prescription.

Once the prescription has been presented, the pharmacy can legally sell the drug to the patient. How the patient pays for it is another matter. Cash or Insurance, it makes no difference from a legal standpoint. (I know there are exceptions to this generality, but this is how it works most of the time).


lol i don't know what kind of candyland you live in but the number of people that are on medicaid that shouldn't be is astounding.
but whether or not someone should or should not be on medicaid is completely irrelevant to what you are asking
you asked if it was illegal for the pharmacy to accept cash payment. the answer is no.

In Illinois, there is a limit of 4 RX's/30 days (they do make exceptions for certain drugs if the doctor does a PA), Medicaid encourages their recipients to pay cash to get any RX's they need over the 4 (and certainly any that require a PA for any other reason.) I've seen some of the PA's put in for being over 4 RX's/30 days denied because because the drug was cheap enough that the case worker thought they should be able to afford it. I think IL Medicaid does keep track of paying cash for narcotics (because of refill too soon) and that can have repercussions.


I don't worry about where they are getting them money to pay for it-its their money, qualifying for Medicaid (at least in IL) doesn't mean that one is destitute with no disposable income.


When it comes to legality for the pharmacy, no it is not. the pharmacy wont get in trouble period. it may prompt an investigation from medicaid to see if the person should really be on medicaid(although highly unlikely). I'm not sure if you were asking as a medicaid recipient or a pharmacist dealing with this situation. You sure don't sound like you practice retail pharmacy. wait for the doctor to authorize the PA? what a joke. Been a retail pharmacist for nearly 2 years. I average about 30-40 PA rejections per day and i can count on my fingers how many times a doctor ever actually went through with the process of a PA. I don't really know what the process for the physician PA's are but it's enough of a hassle where they exhaust every other option before they do it. I remember calling a doctor about getting a PA once. he tried changing the medication 3 times to other medications of the same class. all were not covered. then he started asking the prices of each medication and ended up just picking the cheapest one and told us to tell the patient to pay out of pocket. I got a patient that's been waiting on a PA since January. Called the doctor last week to follow up. "we're working on it". dude's been paying cash for his meds. in your world, he'd pretty much have to walk it off right?


I cant share the link because it violates guidelines but I really think your pharmacist is full of crap.

BlackWarrior
04-28-17, 01:08 PM
I quit my job so that I could go back to school. I'm back on Medi-Cal (state of california) since I have no income now. I tried using my Medi-Cal to pay for my prescription, the insurance company said I didn't qualify because I'm not 16 years or younger. The Walgreens pharmacy had no problems with me paying with my credit card, but then again I am using the GoodRx discount card.

thaney
04-29-17, 12:04 AM
I quit my job so that I could go back to school. I'm back on Medi-Cal (state of california) since I have no income now. I tried using my Medi-Cal to pay for my prescription, the insurance company said I didn't qualify because I'm not 16 years or younger. The Walgreens pharmacy had no problems with me paying with my credit card, but then again I am using the GoodRx discount card.

The second pharmacy I found didn't have a problem with me paying cash either, but CVS wouldn't allow it. I also brought a GoodRx card to CVS, which they told me they'd accept when I dropped off my Rx slip, and then told me they would never accept it for this class of drugs when they were telling me I couldn't pay with cash.

sarahsweets, I too have found all of what you cited over the last few days (not sure if in this forum or others, but I recognize each account). I've also found quite a few accounts of people who were told they could NOT pay for services on their own if they (or their children) had Medicaid.

I don't think I ever suggested it was "illegal," per se, though my pastor suggested it was a federal law, but from what the pharmacist said, it sounded like this was a rule made by Medicaid (at least in my state?) that they expect pharmacies to enforce. Since over half of this particular CVS's business is to provide medication for Medicaid patients, he said they really need to abide by the rule that anyone on Medicaid not be allowed to pay their own way for their meds, otherwise Medicaid could stop covering drugs at CVS, which he implied would hurt CVS since it is so much of their business.

I don't know a whole lot about PAs except that my initial Rx (for Concerta) required one. After waiting for that process for a few weeks, only to have the insurance company deny it anyway, I opted to see if there was an Rx I could afford without insurance (having no idea that this, too, would be problematic).

All I can find in my policy handbook is: "(My policy) may not cover all of your health care expenses. You may be responsible to pay for services if
you have been told ahead of time that (my policy) does not cover the services. It is important to check with your PCP or (my policy's) Member Services to find out which health care services are covered."

This sounds like I can pay out of pocket without a problem?

But that is not what I was told by the pharmacist. I was ready to hand over my money. Why would he not allow that?

ToneTone
04-29-17, 10:32 AM
I did a little googling.

There are stories out there that some pharmacies are under pressure to not give out opiates ... given the opioid abuse epidemic.

Then I found a pharmacist who said that DEA is putting pressure on certain pharmacies not to fill certain prescriptions if DEA thinks there are too many prescriptions (for that medication) at that particular pharmacy.

Here is a pharmacist commenting:

As a pharmacist I can tell you the DEA is putting increasing pressure on us to not fill any CS that we don't feel comfortable with regardless of the reasoning. This can be caused by anything from high doses, lack of sufficient diagnoses, and even questionable patient behavior when dropping it off ...

My store would've had no issue filling this, but it's just frustrating that the regulatory boards crack down on us and not on the MDs and mid-level practitioners in our area that are blatantly over-prescribing.

I remember getting rxs for MS Contin, oxycodone, alprazolam, phentermine, and adderall for one patient from an NP in our area and the scripts said "diagnosis: diabetes" on all 5 of them. I told the patient I had to call the office and she flipped out and called my supervisor to complain. When I got a call from my supervisor later that day she told me to fill the scripts this time after I verified them with the NP because of "customer service" and she'd have our district's lawyer follow up with the DEA about that prescriber's office. 2 weeks later I get a call from my local DEA office saying we're on probation for filling too many Adderall prescriptions that month, and nobody followed up with the offices that I reported as blatant over-prescribers. So because of this we couldn't fill any more stimulant scripts for the rest of the month. Imagine how much our customers appreciated that.

So basically don't get upset at the pharmacy staff until you know the whole story. Because of crackdown by the DEA due to over-prescribing, some pharmacists are being held responsible even for simply dispensing too much of a medication in a certain time-span. Just tell the patient to go somewhere else. There's literally a different pharmacy every 2 miles so the patient can just go elsewhere if they have a bad experience with one, it's no big deal."

[from Reddit thread, pharmacy refusing to fill pain medication]

sarahsweets
04-30-17, 05:58 AM
I really do not think it has to do with medicaid and has more to do with the jerk pharmacist. I personally would find another pharmacy that you have never used before and not tell them about medcaid and tell them you do not have prescription drug insurance and see if they can fill it ;

Lunacie
04-30-17, 10:25 AM
Illegal? Sounds pretty iffy. I could see Medicaid telling you that if you can afford
out-of-pocket scripts you don't qualify for Medicaid. But I don't see how the
pharmacy is going to be held responsible. :scratch:

dvdnvwls
04-30-17, 11:28 AM
Lunacie: it seems pharmacies ARE being held accountable, even though that is blatantly wrong and harms patients.

I guess pharmacists don't fight back as hard as doctors do, so the DEA takes the route they do - but I'm just guessing.

Also, it's been said that DEA appears to have quotas.

sarahsweets
04-30-17, 12:35 PM
When I was googling about this, over and over again I read suggestions on picking a new pharmacy where you havent filled any scripts and telling them you are self pay and have no insurance.

thaney
04-30-17, 06:42 PM
I chose CVS because it has the lowest price around for Adderall. Do you think I could go to a different CVS and that would work, or will I be flagged in their computer somehow?

ToneTone
05-01-17, 12:05 AM
Definitely try a different one in a slightly different area ... I don't think entire chains get flagged as much as specific stores ... that's my sense, at least.

BerryFyne
11-15-17, 08:06 PM
I was refused a medication from CVS (I used to be a PharmTech for CVS) and was told the med wasn't covered by Medi-cal and that I couldn't pay cash. As a previous Pharm Tech I had no clue about this "rule"...

Anyways, I stumbled upon this board just had to share. It's not only opioids. My Rx was for Peridex Oral Rinse for use between dental visits to treat gingivitis.

Average Pricing...Walmart $4.00 Costco $9.00 Albertsons $15.00 Rite-Aid $9.99 CVS $12.00Target $12.00 Walgreens $12.00
Yes.... a mouthwash, no more than $13.00.

sarahsweets
11-16-17, 04:05 AM
So are you saying cvs refused to allow you to pay cash for mouthwash? Was there any type of controlled substance in it?

foreverwarrior
11-17-17, 12:18 PM
Its not an insurance thing imo, its a suspicious CVS thing. The insurance company has no say on something they are not paying for.

^ this. I have state healthcare and have regularly paid out of pocket when something (mostly everything) wasn't covered by Cigna. Walgreens always let me - however i've had experiences at another pharmacy I wont name that starts with CVS say no when insurance approved the med, but at 0% coverage.

I believe insurance wants prior auth to a certain degree even if they pay for nothing - and this keeps you from being boot elligible.

But mainly it is a company policy that they can keep an RX and not hand it over if they "do not feel comfortable".