FINANCIAL POLICY FOR PAYMENT OF PHARMACY SERVICES

Patients are expected to pay for their prescriptions at the time of service by cash, check, or bank card.

Estimates will be given prior to compounding your prescription.

Eastern States Compounding is contracted with a number of pharmacy benefit providers. Please let
our staff know if you have prescription coverage. If we are not contracted
with your particular pharmacy benefit company we will assist you in filing
forms for reimbursement. In this case we require payment at the time of
service and reimbursement, if available, will be paid directly to the
patient. Please bring or fax a copy your insurance card and/or a completed insurance form to your first visit.

For those patients who have established accounts, payment is due on the date your prescription is picked up/mailed or before the next billing date (10th of each month) and can be made by cash, check or bank card.

0.83% per month (10% per year) will be charged on all accounts over $5.00 which are more than 60 days old.

There will be a$30.00 charge on all checks returned for insufficient funds.

Eastern States Compounding Pharmacy provides a limited amount of services pro bono. Each case is evaluated on an individual basis.

RETURN POLICY

State law dictates that once a prescription medication leaves the premises of a pharmacy, it can no longer be returned. Over the counter (OTC) nutritional supplements that are still sealed and not damaged can be returned for a full refund with proof of purchase.

Ph 704.07 Return of Drugs and Devices.

(a) Except as provided in Ph 704.07(b), no drug, prescription, device, sickroom supply or item of personal hygiene which is returned to the pharmacy shall be re-sold or re-dispensed after such item has been taken from the premises where sold, distributed or dispensed.

(b) Exceptions to Ph 704.07 (a) shall include:

(1) Orthopedic appliances;
(2) Crutches;
(3) Canes;
(4) Wheelchairs;
(5) Hospital beds;
(6) Bed rails;
(7) Trapezes;
(8) Other durable equipment that can be properly sanitized; and
(9) Medications dispensed in unit dose packaging to institutionalized patients.

Source. #1639, eff 11-1-80; ss by #2260, eff 1-5-83; ss by #2914, eff 11-27-84; ss by #4600, eff 8-1-89; ss by #6094-B, INTERIM, eff 9-21-95, EXPIRED: 1-19-96

New. #6181-B, eff 2-5-96; amd by #6933, eff 2-1-99; paragraph (b) EXPIRED: 2-5-04; amd by #8316, eff 3-26-05