Pharmacies can be paid in several ways by insurance companies, including a maximum allowable cost per generic drug, a capitation fee where the pharmacy receives a set amount per patient each month regardless of visits, and sharing costs with patients through deductibles and copayments. There are also different types of third party plans like HMOs that require providers and referrals in and out of network, PPOs that pay less for out of network care, and POS plans that require a primary care provider and referrals for specialists. Medicare, Medicaid, and workers compensation may also cover prescriptions, while patient assistance programs can help with affordability.

1. pharm get paid!
•max allowable cost--max price ins co will pay for
generic
•capitation fee- pharm gets paid x per pt per
month, whether or not they come in.
•deductible--ins co pays nothing until pt pays x
amount for medical services.
•copayment--pt pays % of med or x amount and
ins co pays rest.

2. 3rd party plans
• HMO health maintenance organization---providers sign
contract and must follow HMO orders, wont pay outside
network unless referral.
• PPO preferred provider organization---providers contract
with ppo. ins pays less if you go outside PPO.
• POS point of sale/service---prov under contract. pt must
choose PCP on the list. PCP must give referral if outside
network.
• medicare----federal program for over 65? or disabled or
kidney failure.
• medicaid----federal program administered by states who
determine services and entry. not all drugs paid for.
• pt assistance program---drug maker offers assistance for
special needs and affordability.
• work comp---on the job injury. rx billed to ins co.