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Jacksonville woman questions $15,924 prescription cream

7:26 PM, Nov 21, 2013   |    comments
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JACKSONVILLE, Fla. -- Tonight the On Your Side team has a cautionary tale for anyone who gets prescriptions filled.

She said her insurer was billed more than $10,000 and she wants to know why. She turned to the On Your Side team to get answers.

Annie Walton said she lives with pain, so she uses a prescription cream.

"It eases the pain some," Walton said. "But not that much."

Walton was prescribed a compound cream. The prescription included twelve bottles for a 90-day supply. She then saw the cost breakdown of the prescription on her explanation of benefits.

The form shows that Wellhealth Pharmacy, which made her prescription to order, submitted $15,924.57 to Tricare, her government healthcare plan.

Tricare paid $12,827.07.

"I couldn't believe it," she said

Annie's copay? Just $17.

"Who's to blame for this big expense?" She asked, about the price of her prescriptions.

The owner of Wellhealth pharmacy wouldn't talk specifics but said compounding pharmacies like his have additional operating costs. The owner also said the cost of ingredients are set by manufacturers and chemical companies.

Walton said she's concerned that the high cost of a prescriptions like hers could trickle down and raise everyone's healthcare costs.

"Yes!" She emphasized. "Yes, because it's wrong and everybody pays for it."

FCN spoke to another compounding pharmacist who is not connected to any of this. That pharmacist told FCN they would probably charge $1,500 for the same amount of cream at the same dose; not $15,000.

Wellhealth's owner told FCN this case didn't send up a red flag because prescription costs often exceed $10,000 for specialty pharmacies.

The owner said if Tricare notices something unusual, they'll send an auditor, which he said has not happened in this case.

Tricare spokesman, Austin Camacho said he can not talk about a beneficiary's healthcare.

"However, I can assure you that TRICARE's first priority is the safe treatment of patients, not cost. TRICARE does not generally deny or cap the cost for safe, TRICARE covered prescriptions that are prescribed by a provider for beneficiary care. As TRICARE is a government benefit, we do have cost concerns and encourage beneficiaries to discuss using comparable medications that are less costly with their provider. For example, generics instead of name brands."

Camancho went on to say that a compound prescription may have several ingredients and that each ingredient has a different cost.

"Manufacturers establish an average wholesale price (AWP) for each of these ingredients. TRICARE reimbursements may not exceed the AWP. If the prescription does not exceed the AWP, TRICARE pays," Camacho explained.

First For You, what do you do if you have prescription concerns?

1. To report fraud and/or abuse, call 1-800-332-5455 or email fraudtip@express-scripts.com.

2. If you are a Tricare member, Camancho encourages you to go to visit the program's fraud and abuse website.

3. Check your costs. Make sure they are not hitting or affecting your deductible.

4. Shop around. Even if it isn't costing you now, it might later.

5. Contact your healthcare provider.

First Coast News

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