Rite Aid Drug Store wrongful medication billing Rochester New York

You are absolutely correct! Medicare covers nebulizer solutions at Retail Pharmacies, and all you would have to pay is a small percentage rate as your co-payment after your yearly deductable is paid. And, this small co-payment maybe covered if you also have a Medicare supplemental insurance with prescription benefits.

To make sure your pharmacy knows to bill Medicare for nebulizer solutions (or diabetic testing supplies or chemo drugs), always make sure the following information is written on the prescription. (ask your doctor to write it when they write the prescription):
1. Dr's UPIN number - 1 letter followed by 5 numbers (usually).
2. The word "Medicare" and your Medicare ID number.
3. ICD-9 code: a number that is assigned to the condition the medication is treating.
4. Proper directions for use. "Use as Directed" does not work.
5. If you have a supplemental insurance with prescription benefits, write down the OCNA number assigned to that insurance. (see below)

If you have a supplemental insurance with prescription benefits, call them to obtain an OCNA number. An OCNA (Other Carrier Name and Address) number is a 9-digit number (usually) that allows Medicare to bill your private or supplemental insurance with prescription benefits for you. This way the entire cost of the covered medicare prescription is paid for by Medicare and your supplemental insurance with prescription benefits. The covered medication will be free-of-charge to you.


In the future, if you feel that a copay isn't correct, follow the following guide to resolve the situtation:

1. Look at the pharmacy receipt for the medication (not the cash register receipt). And, more specificially, look which insurance is printed. Look for the words "Medicare."

2. If "Medicare" isn't stated on the pharmacy prescription receipt, ask politely which insurance the pharmacy billed. Most of the times the insurance name appears some place on the pharmacy prescription receipt. Differenet pharmacies bill insurance companies (including Medicare) in different ways.

Note: There are serveral companies that pharmacies can use to process claims in real-time. These companies serve as intermediaries for pharmacies and Medicare (or another insurance) to conduct eligibility, drug coverage, and co-pay information. This information is usually submitted electronicly, and in real-time (without a phone call) it is used to calculate eligibility, drug coverage, and co-pay.

2a. Ask the pharmacy associate if they have your Medicare A/B coverage on file. If not, please present your Medicare card to them so your pharmacy can bill Medicare. If they do have your Medicare information on file, ask them to bill Medicare for the nebulizer solution (or testing supplies or chemo treatment medications).

3. If "Medicare" is stated on the pharmacy prescription receipt, and the co-payment is higher than you are used to paying for the exact medication, ask the pharmacy associate to try to reprocess the precription.

Note: The company that your pharmacy uses to bill Medicare might have skipped an eligibility check and sent back what the co-payment would have been if the member has not meet their yearly deductable. When the pharmacy re-processes the prescription the majority of times it will correct itself and an eligibility check will complete and the correct co-payment will be transmitted back to the pharmacy.

3a. If the co-payment did not change, ask the pharmacy associate if they could call to see why there has been a change.

Note: Pharmacies can be a busy place for the staff they have at any given time, so please be patient with them. If you and the pharmacy are in a time-crunch, simply ask them to call you when they found out what has happened or when the co-payment goes back to being normal. On occasion, Medicare requires the patient to call to update their records before claims can be approved or to pass eligibility.


After a 13 days, most pharmacies will not be able to re-process (re-submit) the claim. So it is important to be informed and know the proper way to handle this situation if it comes up and to be able to resolve it quickly without any blood-pressure increase by the consumer or the pharmacy associate.