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I once had to pay a pharmacy a higher copay for a drug than their list price for it. Once they found I had insurance, they said I couldn't just buy it without

I once had to pay a pharmacy a higher copay for a drug than their list price for it. Once they found I had insurance, they said I couldn't just buy it without using my insurance (probably a lie). Is it the pharmacy ripping me off and getting double paid, or is insurance getting a kickback on the copay? I think the first explanation is more likely. Apparently, this is a common thing, but I found it to be puzzling. Just another anecdote of how screwed up our medical system is here in the US. Imagine going to a store and paying higher than retail for an item...

evancox100 8y ago
I believe the pharmacy, who contracts with the insurance company, is obligated to charge you according to their agreement with the insurance co.
- maxerickson 8y ago
  That would be quite a contract that obligated them to ensure a customer was not also a customer of a particular insurance company.
  - dragonwriter 8y ago
    Drug manufacturers have discount programs for uninsured customers (it's price discrimination to get as much money as possible from both insure and uninsured clients); so, if this was involved, requiring that customers had no applicable insurance known to the retailer wouldn't be a surprising contract term at all.
- sjg007 8y ago
  No they are not. You can just take your prescription elsewhere (e.g. to another Walgreens or whatever). For example, say you lose a pack of pills. If you want a refill you then have to pay for it out of pocket since the insurance won't pay. If the pharmacy charges an inflated cash price to an insurance customer vs a regular customer (without a coupon or something) then that would be a major lawsuit waiting to happen. You can use a drug manufacturers coupon too (e.g. they give a PBM code).
nickjj 8y ago
How's this for strange: I once witnessed a situation where a relative of mine had insurance and the price of his prescription was $14.50 with insurance, but it just so happens the medication is also available over the counter and sells for $11.00. This wasn't an "almost" match either. It was the exact same brand, exact same dosage, exact same quantity but in a slightly different box (due to store branding). It even said "prescription strength" right on the OTC box. The really crazy thing is the original prescription the doctor wanted to prescribe was $600 for a 5 day supply of something that needed to be taken for 6 weeks but the insurance company denied it (meanwhile he pays $400 a month for basic insurance). Medical treatment is beyond broken in the US.
- existencebox 8y ago
  Same exact thing happened with my wife's epipen, turned up an order of magnitude. 300$ for a two-pack via insurance. 40$ for a two pack OTC. Pharmacist said _nothing_ and it was only after she called me to be angry about how expensive it was that I realized it was the mylan ripoff and told her to request a generic. And this for a medicine that she'll literally die without. I see red even thinking about this. I don't understand how to get the broader populous to realize how dangerously broken this system is if they haven't by now.
  - treyfitty 8y ago
    I used to think "oh, there's probably a good reason for this" in all facets of life, including healthcare in the US. Then my father had a heart attack, and I was exposed to just how stupid the whole system is. By and large, there are policies, procedures, and business practices that were written with good intentions, but we've evolved into a society where the most important P is Profit. People generally just purchase insurance and think they're "covered." If the whole population only knew how dirty the system is, there'd be change. But simply because of the obfuscated nature of the system, there is no good reason for why things are the way they are.
    - vernie 8y ago
      The profits are a great reason. Not necessarily for your dad, but definitely for some people who couldn't care less about your dad.
jobu 8y ago
That's just a shitty pharmacy. Walgreens tried to do the same thing to me and that's why refuse to do any business there. The local chain I use now is pretty good about helping me find the cheapest option for prescriptions (sometimes there are rebates on branded drugs that make them cheaper than generics). Also, Walmart has a decent list of $4 medications: https://www.walmart.com/cp/4-dollar-prescriptions/1078664 https://www.walmart.com/cp/4-dollar-prescriptions/1078664
- epmaybe 8y ago
  To tack on to this: https://goodrx.com https://goodrx.com GoodRx is also a decent resource for finding reduced cost medication or coupons.
  - russh 8y ago
    Using GoodRx lowered the cost my uninsured girlfriends blood pressure medication by a little over half.
  - 0x00000000 8y ago
    FYI many pharmacies (individual stores that is) do not accept it for certain medications, lie about accepting it, or will change their mind after ordering your medication in order to try and extort you. Get it in writing if they say they will accept it or try and pay in advance or something. Pharmacies are up their with mechanic shops for being overwhelmingly comprised of scumfucks.
sjg007 8y ago
The only reason to pay the copay is that it will reduce your remaining deductible. So you have to weigh the longer term option vs immediate savings.
- mikestew 8y ago
  Deductible or not, I fail to see how it’s not still just wasting money. Yeah, i “weighed the longer term option”, but I still can’t get the math to work.
- pessimizer 8y ago
  This isn't weighing present-value and future-value of money, this is gambling; gambling whether you're likely to get through your deductible or not.
  - sjg007 8y ago
    It’s not gambling. Some people schedule medical procedures accordingly. Some people have complex medical situations etc... insurance isn’t a gamble and not everything is emergent.
haroldp 8y ago
https://www.pbs.org/newshour/health/why-a-patient-paid-a-285-copay-for-a-40-drug https://www.pbs.org/newshour/health/why-a-patient-paid-a-285...
blaisio 8y ago
They were lying. You can buy the drug however you like. There is no legal restriction (unless you're in Medicare or Medicaid, then it gets complicated). Then again, they also don't have to sell it to you. A lot of independent pharmacies do things like that. For pharmacies, it's usually better to go with a chain than your local shop.
munk-a 8y ago
Ha, as a funny opposite example I once had insurance (when I was in the US) that had 100% out of pocket drug coverage (i.e. no insurance) but the price of my drug when from 300$/30 to 120$/30 because of a "preferred rate" for the insurer, which is wonderful because the flipside was that simply having an insurance card saves you money so those unfortunate enough to lack insurance end up being burdened with a completely arbitrary higher price. FYI, a few years down the line a generic of my drug came out and my price went down to 3$/90, so these costs are just 100% BS and caused by artificially enforced monopolies, as soon as actual competition was allowed in the prices quickly leveled out to a sane amount. (Aside, I'd prefer a socialized system in the guise of Medicare for all or what-have-you, but it amuses me that this market is so messed up that even just letting crazy free-wheeling laissez faire market effects to work radically reduces costs)
pg_bot 8y ago
The pharmacist likely has a contract with the PBM that bars them from discussing cash prices with people who are covered by insurance. If the PBM finds out the pharmacy is circumventing them, they can void their contract which will likely put the pharmacy out of business. It's likely that the pharmacy also got screwed by this transaction as the amounts that PBMs clawback are significant for most generic drugs. At our medical clinic, doctors review first line and second line drugs whenever they are prescribing. Along with this they discuss the cash prices based off of goodrx.com, but we're looking into commercial drug databases as well for more detailed pricing. (if you're looking for an open source project to start, create a drug interaction database as all of them are commercial and ludicrously expensive) About a quarter of prescriptions are cheaper if you pay in cash rather than use insurance. If I were in your shoes, I would have taken the prescription to another pharmacy and asked for their cash price.
- refurb 8y ago
  Kudos to your clinic! I wish more physicians thought about cost when making prescribing decisions. The doctors I’ve talked to said “it’s too hard to figure out what a patient’s insurance pays for”. I can’t count the number of times a doctor has prescribed me a costly branded drug without even trying a generic drug first. The difference even with insurance is often significant.

evancox100 8y ago

I believe the pharmacy, who contracts with the insurance company, is obligated to charge you according to their agreement with the insurance co.

maxerickson 8y ago
That would be quite a contract that obligated them to ensure a customer was not also a customer of a particular insurance company.
- dragonwriter 8y ago
  Drug manufacturers have discount programs for uninsured customers (it's price discrimination to get as much money as possible from both insure and uninsured clients); so, if this was involved, requiring that customers had no applicable insurance known to the retailer wouldn't be a surprising contract term at all.
sjg007 8y ago
No they are not. You can just take your prescription elsewhere (e.g. to another Walgreens or whatever). For example, say you lose a pack of pills. If you want a refill you then have to pay for it out of pocket since the insurance won't pay. If the pharmacy charges an inflated cash price to an insurance customer vs a regular customer (without a coupon or something) then that would be a major lawsuit waiting to happen. You can use a drug manufacturers coupon too (e.g. they give a PBM code).

nickjj 8y ago

How's this for strange: I once witnessed a situation where a relative of mine had insurance and the price of his prescription was $14.50 with insurance, but it just so happens the medication is also available over the counter and sells for $11.00. This wasn't an "almost" match either. It was the exact same brand, exact same dosage, exact same quantity but in a slightly different box (due to store branding). It even said "prescription strength" right on the OTC box. The really crazy thing is the original prescription the doctor wanted to prescribe was $600 for a 5 day supply of something that needed to be taken for 6 weeks but the insurance company denied it (meanwhile he pays $400 a month for basic insurance). Medical treatment is beyond broken in the US.

existencebox 8y ago
Same exact thing happened with my wife's epipen, turned up an order of magnitude. 300$ for a two-pack via insurance. 40$ for a two pack OTC. Pharmacist said _nothing_ and it was only after she called me to be angry about how expensive it was that I realized it was the mylan ripoff and told her to request a generic. And this for a medicine that she'll literally die without. I see red even thinking about this. I don't understand how to get the broader populous to realize how dangerously broken this system is if they haven't by now.
- treyfitty 8y ago
  I used to think "oh, there's probably a good reason for this" in all facets of life, including healthcare in the US. Then my father had a heart attack, and I was exposed to just how stupid the whole system is. By and large, there are policies, procedures, and business practices that were written with good intentions, but we've evolved into a society where the most important P is Profit. People generally just purchase insurance and think they're "covered." If the whole population only knew how dirty the system is, there'd be change. But simply because of the obfuscated nature of the system, there is no good reason for why things are the way they are.
  - vernie 8y ago
    The profits are a great reason. Not necessarily for your dad, but definitely for some people who couldn't care less about your dad.

jobu 8y ago

That's just a shitty pharmacy. Walgreens tried to do the same thing to me and that's why refuse to do any business there. The local chain I use now is pretty good about helping me find the cheapest option for prescriptions (sometimes there are rebates on branded drugs that make them cheaper than generics). Also, Walmart has a decent list of $4 medications: https://www.walmart.com/cp/4-dollar-prescriptions/1078664 https://www.walmart.com/cp/4-dollar-prescriptions/1078664

epmaybe 8y ago
To tack on to this: https://goodrx.com https://goodrx.com GoodRx is also a decent resource for finding reduced cost medication or coupons.
- russh 8y ago
  Using GoodRx lowered the cost my uninsured girlfriends blood pressure medication by a little over half.
- 0x00000000 8y ago
  FYI many pharmacies (individual stores that is) do not accept it for certain medications, lie about accepting it, or will change their mind after ordering your medication in order to try and extort you. Get it in writing if they say they will accept it or try and pay in advance or something. Pharmacies are up their with mechanic shops for being overwhelmingly comprised of scumfucks.

sjg007 8y ago

The only reason to pay the copay is that it will reduce your remaining deductible. So you have to weigh the longer term option vs immediate savings.

mikestew 8y ago
Deductible or not, I fail to see how it’s not still just wasting money. Yeah, i “weighed the longer term option”, but I still can’t get the math to work.
pessimizer 8y ago
This isn't weighing present-value and future-value of money, this is gambling; gambling whether you're likely to get through your deductible or not.
- sjg007 8y ago
  It’s not gambling. Some people schedule medical procedures accordingly. Some people have complex medical situations etc... insurance isn’t a gamble and not everything is emergent.

haroldp 8y ago

https://www.pbs.org/newshour/health/why-a-patient-paid-a-285-copay-for-a-40-drug https://www.pbs.org/newshour/health/why-a-patient-paid-a-285...

blaisio 8y ago

They were lying. You can buy the drug however you like. There is no legal restriction (unless you're in Medicare or Medicaid, then it gets complicated). Then again, they also don't have to sell it to you. A lot of independent pharmacies do things like that. For pharmacies, it's usually better to go with a chain than your local shop.

munk-a 8y ago

Ha, as a funny opposite example I once had insurance (when I was in the US) that had 100% out of pocket drug coverage (i.e. no insurance) but the price of my drug when from 300$/30 to 120$/30 because of a "preferred rate" for the insurer, which is wonderful because the flipside was that simply having an insurance card saves you money so those unfortunate enough to lack insurance end up being burdened with a completely arbitrary higher price. FYI, a few years down the line a generic of my drug came out and my price went down to 3$/90, so these costs are just 100% BS and caused by artificially enforced monopolies, as soon as actual competition was allowed in the prices quickly leveled out to a sane amount. (Aside, I'd prefer a socialized system in the guise of Medicare for all or what-have-you, but it amuses me that this market is so messed up that even just letting crazy free-wheeling laissez faire market effects to work radically reduces costs)

pg_bot 8y ago

The pharmacist likely has a contract with the PBM that bars them from discussing cash prices with people who are covered by insurance. If the PBM finds out the pharmacy is circumventing them, they can void their contract which will likely put the pharmacy out of business. It's likely that the pharmacy also got screwed by this transaction as the amounts that PBMs clawback are significant for most generic drugs. At our medical clinic, doctors review first line and second line drugs whenever they are prescribing. Along with this they discuss the cash prices based off of goodrx.com, but we're looking into commercial drug databases as well for more detailed pricing. (if you're looking for an open source project to start, create a drug interaction database as all of them are commercial and ludicrously expensive) About a quarter of prescriptions are cheaper if you pay in cash rather than use insurance. If I were in your shoes, I would have taken the prescription to another pharmacy and asked for their cash price.

refurb 8y ago
Kudos to your clinic! I wish more physicians thought about cost when making prescribing decisions. The doctors I’ve talked to said “it’s too hard to figure out what a patient’s insurance pays for”. I can’t count the number of times a doctor has prescribed me a costly branded drug without even trying a generic drug first. The difference even with insurance is often significant.