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Denial Conversion Allows Commercial Insurance Patients to Receive Preferred, but Non-Formulary Medications, and Discounts Offered by MFG through PrimeRx™

At the start of 2022, as they do every year, health plans nationwide announced changes to their formularies, adding certain new drugs while removing others that had been previously included. According to CoverMyMeds, this annual exercise allows health plans “to make way for new, improved medications, control costs and give patients better treatment options.”

While these may be worthy objectives, the formulary changes can have profound effects on patients.

As noted by CoverMyMeds, major plans excluded roughly 100 medications from their formularies during 2022. This includes Express Scripts National Preferred Formulary (32 new exclusions, including five specialty drugs), CVS Caremark Commercial (20 new exclusions), and United Healthcare Commercial (50 drug exclusions, many of which were replaced by generic alternatives).

While patients do have options when a prescribed drug is not on their formulary, namely through the prior authorization or direct appeals processes, such efforts can take time, with no guarantee of a favorable outcome.

Now though, there is a better way. Namely, through Micro Merchant Systems’ technology-based Denial Conversion Program, which is a key function of the PrimeRx™ pharmacy technology system. Through the Denial Conversion Program pharmacies provide patients with medications rejected by a payer through reimbursement for the costs from Micro Merchant Systems. Patients leave the pharmacy with their preferred medications, and pharmacies receive real-time notification of the discounted patient copay plus the amount the pharmacy will be reimbursed, in addition to a $2.00 transaction administrative fee.

Important to note, while denial conversion services are offered by certain manufacturers, Micro Merchant Systems is the only technology company that offers this service directly to pharmacies through its PrimeRx™ pharmacy software. Following is an overview of how the solution works:

  • A patient’s prescription is entered into PrimeRx™ and routed to the appropriate payer.
  • Should the claim be rejected by the payer as “non-reimbursable for a qualified National Drug Code (NDC),” the MMS denial conversion solution will intervene.
  • The rejected claim is automatically converted to “paid” status, and a message is sent to the pharmacist confirming that the cost of the medication will be covered through the MMS Conversion Denial program.
  • Micro Merchant Systems reimbursements:
    • For each denial conversion transaction, the pharmacy is paid a sum that equals the Wholesale Acquisition Cost (WAC) plus 7.5%, less the patient responsibility amount.
    • The pharmacy is paid a $2.00 administrative fee for each denial conversion transaction. This fee is intended to offset the pharmacy’s administrative and processing costs.
    • Payments will be made by Micro Merchant Systems at the end of the month in which the transaction occurred. Denial conversion-related payments will be reconciled against any pending MMS invoices, with the balance posted to the pharmacy’s bank account.
    • The pharmacy will receive an electronic notification when a reimbursement has been made.

The MMS solution also offers eVoucher services, which allow a pharmacy to automatically identify and apply manufacturer co-pay coupons at point-of-sale. Electronic coupons have become an important way to help patients reduce, sometimes even eliminate, out-of-pocket costs.

2022 research by Kaiser Family Foundation (KFF) found roughly half of U.S. adults expressed difficulty in affording health care costs, with about 40 percent of patients either delaying or choosing to go without care. Denial conversion and eVoucher services offer critical lifelines to help address this serious situation. Denial conversion allows patients another option to receive the medications their prescribers believe will work best for their condition, while eVouchers help reduce out-of-pocket costs.

With the PrimeRx™ MMS eVoucher & Denial Conversion Services solution pharmacies have ready access to these patient-serving capabilities. It couldn’t be easier, or more beneficial.

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