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Question:

From New Jersey, USA:

My doctor recently prescribed Glucotrol, glucose test strips, and disposable lancets, and when I went to my pharmacy to have the prescriptions filled, the pharmacist said that although I do have health insurance and prescription plan coverage, it only covered the Glucotrol, but not the diabetes strips and lancets. He then told me that I had to pay in full, which I did. I called my medical insurance and related this experience and was told that although I was not covered by the prescription plan, I was covered by the health insurance plan. They said that the pharmacist, after being told of this coverage, should have known, not charged me, and be prepares to file a claim with my insurance for the diabetes supplies.

Is there a national or New Jersey state law that requires the pharmacist to fill the prescription for the test strips and lancets, without requiring me to pay out of pocket? Does it require him to file a claim with my medical insurance for the cost of those supplies? If there is such a law or regulation, could you cite it for me?

Answer:

New Jersey has a law which, since 1995, requires insurance companies subject to state regulation to provide coverage for medically necessary diabetes equipment, supplies and self-management training. You can find it at NJ Statutes 17:48A-71.2. However, the law does not require a pharmacist to provide your strips and supplies for no cost or even require that they file a claim with your insurer on your behalf. Your pharmacy filed a claim on your behalf for your oral diabetes medication because it has an agreement with your pharmacy benefit provider (the part of your health insurance that covers prescription drugs).

What your insurance company did not tell you is that your diabetes strips and supplies are covered under the major medical portion of the policy, and even though you paid out of pocket for these items at the pharmacy, your insurer should allow you to submit a claim to be reimbursed for these items, minus any copayment or deductible. You should call your insurance company again and ask them if they have a relationship with a medical supply company where you can get your strips and supplies without having to pay more than your copayment and the supplier files its claim directly with your insurer. Sometimes this might involve doing business with a supplier through the mail.

DSH

DTQ-20030124125257
Original posting 26 Jan 2003
Posted to Insurance/Costs

  
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Last Updated: Tuesday April 06, 2010 15:09:42
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