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How to Submit Prescriptions for Cancer Drugs Dispensed by Physicians

by Marie Kaye

Overview

The practice of medicine has faced increasing financial pressures as overhead continues to rise without offsetting increases in insurer reimbursement. In states permitting physician-dispensed prescription drugs, many doctors find that offering a point-of-care option for cancer drug purchase is a convenience to patients and a profitable venture for the physician's office. Prescription drugs for cancer can be quite expensive, so it is important that patients submit prescription drug claims to the insurer quickly and correctly.

Step 1

Request that the physician fill out and submit prescription reimbursement claims and charge the patient the co-payment. The easiest way to make sure that prescription claims are submitted correctly and avoid unnecessary out-of-pocket costs is to request that the physician collect the co-payment and bill the insurer directly. If the physician office is not willing to submit prescriptions to the insurer, proceed to the next steps.
Step 2

Become familiar with the insurer requirements for the particular cancer drugs dispensed by the physician. The rising cost of health care has driven insurers to implement a variety of checks and balances, and even potential obstacles, in covering expensive cancer drugs. Prior authorization is a common restriction, and is most easily understood as the insurer requiring the physician to get a green light on a particular therapy before dispensing and expecting payment for it. Even on-label uses of cancer drugs can be subject to prior authorization. Failing to go through appropriate insurer channels prior to having a prescription dispensed by the physician can result in claim denials. The physician's office should be willing to submit any required documentation without charging the patient for doing so.
Step 3

Fill out the patient information on the claim form accurately. This information includes the primary policyholder's name, the name of the patient, the insurance member and group number, and other information required to identify the policy and patient.
Step 4

Request that the physician fill out the "pharmacist" portions of the claim form. If a diagnosis is required, it should be the symptom or condition for which the medicine is needed. For example, if a pain medication is dispensed, the "diagnosis" would be "pain" or "cancer pain." A chemotherapy or other disease-modifying drug would be accompanied by the specific cancer diagnosis.
Step 5

Attach the receipt(s) for the dispensed drug(s) to the claim form, and make sure that the drug name, dosage and quantity dispensed match the receipt.
Step 6

Follow insurer instructions for mailing or faxing claim forms and receipts. Most insurers require that claims be submitted within a specific time period, and that they be sent to a special prescription drug claim address.
Step 7

Follow up with the insurer if reimbursement is not received within three weeks. If the claim for cancer drugs dispensed by a physician was denied by the insurer, contact the physician and request that he contact the insurer to appeal the denial. Most insurers have an informal appeal process that can be used before submitting a formal, written appeal.

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Prescription drug claim form Receipt for drug purchase Policy number from health insurer
Prescription drug claim form
Receipt for drug purchase
Policy number from health insurer
Physician-dispensed cancer drugs are offered as a convenience to patients and are profitable to physicians. A physician's office cannot require that patients purchase drugs from the office.
Physician-dispensed cancer drugs are offered as a convenience to patients and are profitable to physicians. A physician's office cannot require that patients purchase drugs from the office.