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Old 06-20-2011, 09:34 AM   #21
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with my insurance I have a 1600 out of pocket deductible and then the insurance pays 100 percent for everything. I can't see how that would defraud the insurance co. but I used to have the copays and I see what you mean. but the way it is now I don't care what it costs because I will hit the 1600 either way.
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Old 06-20-2011, 09:36 AM   #22
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Originally Posted by Ronnieboy View Post
It would be fraud if your insurance is paying for (and charging you for) 1 month supply but it is knowingly lasting you two months (your insurance would expect you to pay two copays). That would be insurance fraud, not really defrauding the manufacturer. If your paying fully out of pocket then it shouldn't really matter.
I don't understand.
Using actual figures: Lipitor 80mg, 90 days supply. I pay $102 and the company pays $238. I split the pills, so now I have 180 days, allowing me to skip the 2nd 90 days order. I save $102 and the company $238. I saved $102 but the company or the insurance was not out of any money. Who got defrauded?
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Old 06-20-2011, 09:42 AM   #23
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that was my question also. I figured if the drug cost the same for 2 months as it did for one the insurance company wouldn't have to pay for the second prescription either. but with the goblledegoop the insurance companies call billing these days how do you know how much they actually pay? somewhere along the line someone is not making the money they thought they should. but the question is who?
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Old 06-20-2011, 10:03 AM   #24
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With just a little effort anybody can get Lipitor at generic prices now.

Lipitor $4 Copay Card
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Old 06-20-2011, 10:33 AM   #25
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Am just about to enter Medicare, and am trying to figure out the right strategy. All the drugs that DW and I take are generics. We need a drug plan 'in case". However, the cost of getting these meds through the drug plan aren't significantly different than getting them from Costco. In fact, Costco is cheaper for Losartan, than the "subsidized" price under the drug plan.

Looks like the cheapest drug plan would be about $35-$40 a month for each of us. We also have an option to continue on a plan from my old employer which would cost more out of pocket for Dr. visits etc., but doesn't have the doughnut hole for meds. With the prevalence of drug treatments for lots of ailments that we don't have but might get, maybe we should take the company plan. Have to make up my mind by the end of the month.
As I noted in my original post, you have to look at ALL the options. For example: I'm taking a generic prescription that costs $6 for a 90 day supply through my health care provider mail-in pharmacy. I get the same '
deal through WalMart. I opt for the WalMart deal because that $6 does not count toward the donut hole. If I use my health care mail-in provider, it cost the same $6; however, that $6 is added to their cost which is $195, so I accummulate $206 toward the donut hole.
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Old 06-20-2011, 08:25 PM   #26
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Originally Posted by KingB View Post
I don't understand.
Using actual figures: Lipitor 80mg, 90 days supply. I pay $102 and the company pays $238. I split the pills, so now I have 180 days, allowing me to skip the 2nd 90 days order. I save $102 and the company $238. I saved $102 but the company or the insurance was not out of any money. Who got defrauded?

Using your example, if you were taking Lipitor 80mg, at 1/2 tab #45 would last 90 days. Your copay would still be $102 and the insurance would pay roughly half of the amount listed above ~ $119.
90 days later you get your refill, you again pay $102 copay and the company pays $119.

Now over the 6 months you have paid $204 and the insurance has paid $238.

The insurance can now say they provided 6 months of benefits for the $238 (where in your example it only looks like 3 months even if you don't get the 2nd refill for 6 months), but it has cost you double and believe you me - insurance companies have done numerous studies that show the more you (the patient) pays out of pocket, the more you are invested in your health care dollars (now I am going to look for the alternative - simvastatin instead of Lipitor because my 90 day copay drops to $10 and the insurance company pays nothing b/c your $10 copay is the full amount).

We're not even getting into any type of back end deal the insurance or mail order company is getting from the manufacturer.

It is similar to people on Medicaid who have $0 copay for office visits. Not only do they go to the ER for the everyday visits (instead of having a primary care physician, which would be more cost effective), but they go more often. For any scrape, cough, or sniffle. When asked why, "It doesn't cost me anything"
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