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go out of network for pharmacy?
Old 06-11-2010, 11:38 AM   #1
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go out of network for pharmacy?

Hmmmm....trying to make a decision here. I think I know the way I want to go, but wanna run it by the savvy minds of this board first.

First, for those who don't know me, not FIRED yet. DH and I are covered by his work benefits. His benefits options changed in 2010. We chose a high ded plan with an HSA.

The high ded costs us $450 a year in payroll deductions. The deductible is $3200.

Pharmacy coverage does not kick in until after the deductible is met. We are pretty healthy and our total health care costs (including prescription drugs) were around $4K in 2008 and $2600 in 2009.

Now that we have a deductible, I am looking at our prescription costs closely. A big chunk of it is due to a Nexium prescription. Through the network plan it costs $3.40/pill. If I take 1 pill a day, that adds up to $1241/yr (on top of that I do occasionally take 2 a day). Yikes! I found another company where I can buy it for $2.19/pill ($799/yr) or their generic version for $1.66/pill ($606/yr). (This company comes highly recommended by a friend of mine who has used them for several years.)

The caveat is if I go out of network for pharmacy, it does not count towards my deductible.

I'm leaning towards going out of network since we've only met $139 towards our deductible so far this year (been really healthy, knock on wood). I think the chances of us actually meeting the $3200 deductible, even if I buy the network Nexium is pretty low. However, I just want to make sure I am not overlooking something.

Thoughts?
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Old 06-11-2010, 02:43 PM   #2
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What's the goal? To pay the Deductible? To pay the lowest amount for the same product? Maybe I don't understand the question.

(Oh! I see, the only question is "Thoughts?")
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Old 06-11-2010, 03:51 PM   #3
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I'd go to lower my meds cost - that's a sure thing.
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Old 06-11-2010, 04:04 PM   #4
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sg, my family is in a very similar situation with a high deductible plan and a $3000 annual deductible. DH's blood pressure medicine cost $30/month at an in-network place and $9/mo out of network at another major pharmacy chain. We go out of network to save ourselves the money. Why give away $21 a month?

The high deductible plans do make you want to be an informed savvy shopper - because you are spending your own money. We've not ever come close to meeting the $3000 deductible in the two years we've had the plan - and I wouldn't consider this monthly medication the tipping point to get us closer to the $3k (Spending $108/yr out of network vs $360/yr in network).

I vote for shopping for the better deal unless you believe you're going to hit that tipping point.

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Old 06-11-2010, 10:04 PM   #5
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Quote:
Originally Posted by simple girl View Post


Now that we have a deductible, I am looking at our prescription costs closely. A big chunk of it is due to a Nexium prescription. Through the network plan it costs $3.40/pill. If I take 1 pill a day, that adds up to $1241/yr (on top of that I do occasionally take 2 a day). Yikes! I found another company where I can buy it for $2.19/pill ($799/yr) or their generic version for $1.66/pill ($606/yr). (This company comes highly recommended by a friend of mine who has used them for several years.)



Thoughts?
Well, there is no generic for Nexium in the U.S. yet, so to get a generic you must be going out of the Country. I would be wary of where you were getting it, unless it was Canada (for sure).

I would say if you are 100% sure you are not going to hit the deductible then go out of network.

I would also look at generic alternatives that are available here and not only get a better price, but have it go towards the deductible.

Generic Prilosec is available and is the precursor to Nexium, maybe constant 2xday dosing would work?
Generic Prevacid is available but still expensive till more manufactures enter the arena, a couple more months?

Good Luck
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Old 06-11-2010, 10:26 PM   #6
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simple girl,

Another point which I don't think has been mentioned yet, regardless if you go in-network or out of network, the part you pay out of pocket would be reimburseable to yourself sometime in the future from the HSA if you decide to go that route rather than trying to not reimbursement yourself as use it as a future IRA. That said, I'd try for the less out of pocket instead of trying to meet the deductible. That is, as long as it's safe (as previously mentioned).
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Old 06-12-2010, 06:51 AM   #7
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Well, there is no generic for Nexium in the U.S. yet, so to get a generic you must be going out of the Country. I would be wary of where you were getting it, unless it was Canada (for sure).

Generic Prilosec is available and is the precursor to Nexium, maybe constant 2xday dosing would work?
Generic Prevacid is available but still expensive till more manufactures enter the arena, a couple more months?

Good Luck
Yes, I'm a bit concerned about the generic. You are right, it would be from out of the country...I would investigate that VERY close before pursuing it. Even if I just go with their Nexium price I am saving a good bit, though.

I initially tried Prevacid, and it did not work for me. I may eventually try the generic Prilosec...but I am nervous about using anything other than Nexium. I was really sick with my reflux before Nexium got it under control, so I'm worried about trying anything else. I think after we FIRE, and I am under less stress, I might play around more with the generics.

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simple girl,

Another point which I don't think has been mentioned yet, regardless if you go in-network or out of network, the part you pay out of pocket would be reimburseable to yourself sometime in the future from the HSA if you decide to go that route rather than trying to not reimbursement yourself as use it as a future IRA. That said, I'd try for the less out of pocket instead of trying to meet the deductible. That is, as long as it's safe (as previously mentioned).
That is a good point, and I will be sure to keep good records.

Thanks all for being my sounding board and for the feedback!
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Old 06-12-2010, 07:45 AM   #8
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I would not be afraid of the generics even if they are frrom Canadian pharmacies. I have to take Plavix, and while there is a generic available, it is not allowed to be sold by American drug companies. Law suit won by the drug company. I take the generic through a Canadian pharmacy. Canadian's get it from an Indian companywhich is approved by the FDA. Still cost me $60 for a 90 day supply but better than $180 for a 90 supply of the brand through my insurance plan. My goal during the year is to do everything I can to stay away from the donut hole established in the Medicare program. I buy some drugs from Walmart under their $4/generic program, one from Canadian Meds and two from my health plan.
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Old 06-12-2010, 09:01 AM   #9
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I would not be afraid of the generics even if they are from Canadian pharmacies................
I live not far from the Canadian border (Windsor). We have lots of poisoned Canadians come staggering over the border from all their inferior drugs.
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Old 06-12-2010, 09:53 AM   #10
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Nexium (esomeprazole) is an obscenely over-priced copycat drug. Essentially the only value it adds over generics is a down payment on a new yacht for the pharmaceutical CEO.

Generic over-the-counter omeprazole is equivalent for most patients. Ask your doctor whether switching is OK, and what dose he/she wants you on.
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As if you didn't know..If the above message contains medical content, it's NOT intended as advice, and may not be accurate, applicable or sufficient. Don't rely on it for any purpose. Consult your own doctor for all medical advice.
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Old 06-12-2010, 12:05 PM   #11
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Nexium (esomeprazole) is an obscenely over-priced copycat drug. Essentially the only value it adds over generics is a down payment on a new yacht for the pharmaceutical CEO.

Generic over-the-counter omeprazole is equivalent for most patients. Ask your doctor whether switching is OK, and what dose he/she wants you on.
Thanks Rich, I will do that indeed.
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simple girl
less stuff, more time

(49, married; DH 53. I am fully retired as of 2015 (well ok, I still work part-time but only because I love the job and have complete freedom to call off if I want to travel with hubby for work), DH hopes to fully retire 2018 when he turns 55 to access 401K penalty-free...although he may decide to do part-time consulting)
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Old 06-12-2010, 10:21 PM   #12
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I would not be afraid of the generics even if they are frrom Canadian pharmacies. I have to take Plavix, and while there is a generic available, it is not allowed to be sold by American drug companies. Law suit won by the drug company. I take the generic through a Canadian pharmacy. Canadian's get it from an Indian companywhich is approved by the FDA. Still cost me $60 for a 90 day supply but better than $180 for a 90 supply of the brand through my insurance plan. My goal during the year is to do everything I can to stay away from the donut hole established in the Medicare program. I buy some drugs from Walmart under their $4/generic program, one from Canadian Meds and two from my health plan.

I wouldn't hesitate using Canadian pharmacies/medications either. I would just make sure it is coming from said pharmacy, instead of some online mock up of a Canadian pharmacy.
The reason Canada gets generics earlier is they have a shorter limit on patent protection than the US of A.
Look for a generic Plavix in the U.S. in about a year.
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