I was, well, moderately furious, at the latest pharmacy campaigns. So many are now designed to indicate " we accept all policies, so your costs are the same no matter what".
It's true that by accepting an insurance plan, a pharmacy agrees to charge prices negotiated with the insurance plan. This does not necessarily mean that your total prescription costs will be the same at that pharmacy.
Unless you have outstanding insurance that covers 100% of every drug (in which case you are probably paying WAY too much for insurance) at some point you will probably be paying the higher rates of the standard pricing at that pharmacy.
Why?
There are limits on coverage. If you have a step program, a tier program, a limited formulary, a co-pay, a deductible, a ceiling, a percentage discount card, or any other expense NOT covered by your insurance, the pharmacy can charge you it's regular prices. If it's not COVERED by your insurance, the pharmacy charges the PHARMACY rates.
Look at the language in your policy. For example, from the standard medicare guidelines:
Standard Coverage (the minimum coverage drug plans must provide):
If you join in 2006, for covered drugs you will pay a monthly premium (varies depending on the plan and coverage you choose)...
...Step therapy is a type of prior authorization. With step therapy, in most cases, you must first try certain less expensive drugs that have been proven effective for most people with your condition. For instance, some plans may require you to first try a generic drug (if available), then a less expensive brand-name drug on their drug list, before you can get a similar, more expensive brand-name drug covered.
If you have been on the "expensive brand-name drug", which include things like Allegra and Imitrex, and have already found they are the most effective for you, you may be paying out of pocket unless (and until) it is determined that the other drugs are "officially" not as effective. In the meantime, NOT COVERED means it does NOT fall under the prices agreed to by your insurance company.
There may also be QUANTITY LIMITATIONS...
For safety and cost reasons, plans may limit the quantity of drugs that they cover over a certain period of time./ In some cases these quantities are fairly low...a policy may cover Zoloft at 50 mg a day, even though 150 mg is a standard dose. Whatever is not covered, again, is not necessarily subject to the insurance price agreements.
Formularies are even more difficult; very few insurance include newer drugs in their formularies. A formulary typically covers at least two drugs in a class. However, this translates to two SSRI antidepressants, for example. Prozac, which is available cheaply as a generic drug, is likely in the formulary, while Cymbalta, a newer and non-generic drug, is likely not. The effectiveness of SSRIs is highly individualized, but your coverage is probably not.
So, choosing a pharmacy can have a huge impact on your drug costs. It did mine. And so, I will blog on tips to evaluate your prescription costs.
Evaluating Prescription Costs
May 15th, 2006 at 08:16 pm
4 Responses to “Evaluating Prescription Costs”
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May 15th, 2006 at 08:45 pm 1147725959
I have bipolar disorder and it can be effectively managed under the right medications. For me, these medications are all brand name with no generic options and often run several hundred dollars a month (pre-insurance). My current plan had a limit on how much it would spend on prescriptions that I wasn't initially aware of. Within just a few months, I came very close to that limit and took out a supplemental prescription plan to make up the difference.
The supplemental plan was also useful because it lowered my copays. Even though generics are not available, I'm still charge the highest copay for brand name mental health drugs. I was easily paying $100 a month in copays and that was more than my budget could handle at the time.
May 15th, 2006 at 08:57 pm 1147726623
May 16th, 2006 at 06:24 pm 1147803851
September 28th, 2006 at 11:46 pm 1159487185