How Prescriptions Are Processed And Filled
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Your doctor prescribes a medicine for you at the doctor’s office by either writing a handwritten prescription or sending it electronically to your pharmacy. This could be a retail pharmacy, a pharmacy at your doctor’s office or a mail-order pharmacy.
The pharmacist or pharmacy benefits manager (an organization that manages insurance coverage of medicines) checks your insurance plan to make sure the medicine prescribed is covered by your insurer.
Your health insurer will make one of the following decisions so that you can get your medicine.
- You get the medicine your doctor prescribed by making the co-payment outlined in your insurance plan.
- You can get the medicine your doctor prescribed but it requires a higher co-pay or you have to pay a percentage of the medicine’s cost, called co-insurance.
- You can receive a medicine that has similar benefits and is less expensive to you and your health insurer, but it is not a generic equivalent to what medicine you were prescribed.
- Your insurer would like you to try a different medicine that you must fail on before the insurance company will pay for the medicine your doctor prescribed.
The pharmacist will communicate to you what medicine you can have and how much it will cost to you. Now you must decide which medication to choose based on your doctor’s recommendation, the cost to you and other factors that may be important to you. You may want to consult with your doctor to help make this decision.
Once a decision has been made, you pick up the prescription at the pharmacy or have it mailed to you. In some instances, the pharmacist may not know how much you’re paying for the medicine until the prescription has been filled by them and charged at the register.
Barriers To Access
There are several reasons why you might not be able to get the prescription medicine your doctor believes is the best treatment for your disease or medical condition.