Kaiser Pharmacy copay/deductable question ACA

[RetiredAndLovingIt]

My Blue Shield Pharmacy co-pay is $16 after deductible is met for Tier 1 drugs but last week I was charged a lot less, $3 and $8 for 2 different antibiotics and it's not the first time. I have not met my deductible. I seem to remember a letter from them about the price of drugs possibly being less than the copay and if so would pay the lesser amount. Is that the norm for all ACA plans or are they just being nice? I'm thinking of moving to a bronze plan for 2020 with Kaiser and wondering if the same policy happens with them. I'm also wondering if I can take a Kaiser prescription to an out of network pharmacy to be filled if it turned out to be quite a bit cheaper elsewhere?

[Sarah S]

I get drugs from caremark by mail and I am charged the real price is it is less than copay. 3 months of one prescription is 1.45. You wouldn’t think the mailing, processing . Bottle, label and bag it is sent in would be paid for even. For drugs that are not likely to be abused it seems as if it would be more efficient and cost effective to send a year at once!

[Brat]

I really don't know but I do know that Kaiser buys drugs by the carload and bids where possible, encourages members to order ongoing prescriptions at a mail-order facility. Very efficient.

There may be laws that limit dispensing, a year at a time isn't cost-effective because a patient's needs change. It annoys me that a prescription isn't valid for more than a year. Repeat contacts with a PCP for routine meds don't seem cost-effective. My other complaint is that a "month" is only 30 days.

[cathy63]

Kaiser will give you a paper prescription that you can take to any pharmacy if you ask for one, otherwise it's issued electronically and you just go to the K. pharmacy (often in the same building where your doc practices) to retrieve your meds. If you do take a paper Rx to a non-Kaiser pharmacy you'll pay whaterver the pharmacy's market price is and it doesn't count towards your deductible or max OOP amount. I'm guessing there might be meds, such as opioids, where they will not give you a paper Rx, but it shouldn't be a problem for ordinary things.

Our Kaiser group (So Cal) is also doing some partnership with Target clinics now. I got an email about this a few weeks ago, but I did not read it carefully, because my doctor and pharmacy are already closer than the nearest Target. There should be something on the kp.org website if there are outside partner clinics or pharmacies in your area of coverage.

[Vacation4us]

Quote:

Originally Posted by RetiredAndLovingIt My Blue Shield Pharmacy co-pay is $16 after deductible is met for Tier 1 drugs but last week I was charged a lot less, $3 and $8 for 2 different antibiotics and it's not the first time. I have not met my deductible. I seem to remember a letter from them about the price of drugs possibly being less than the copay and if so would pay the lesser amount. Is that the norm for all ACA plans or are they just being nice? I'm thinking of moving to a bronze plan for 2020 with Kaiser and wondering if the same policy happens with them. I'm also wondering if I can take a Kaiser prescription to an out of network pharmacy to be filled if it turned out to be quite a bit cheaper elsewhere?

The answer is no and no. Kaiser will charge you your co pay even if the medication is cheaper. Since Kaiser orders all prescriptions electronically you would have to find a physician who is willing to write a paper rx. Some will most wont.

Kaiser is a former employer of mine.

[RetiredAndLovingIt]

I did a little internet research after asking my question and I was able to find that California actually passed a law effective this year that we can't be overcharged on prescriptions. For once this is a good law to come out of our legislators and hopefully other state will/have followed.
Limit on Prescription Costs

November 13, 2018

On Sept. 26, 2018, Gov. Brown signed AB 2863 into law. The new law, effective Jan. 1, 2019, limits the amount that a health plan participant will pay for a covered prescription at the point of sale at the pharmacy. Specifically, a participant will pay the applicable cost-sharing amount (copayment or coinsurance) or the retail price, whichever is less. A participant cannot be required to pay a cost-sharing amount that exceeds the retail price.

[Sunset]

Quote:

Originally Posted by RetiredAndLovingIt I did a little internet research after asking my question and I was able to find that California actually passed a law effective this year that we can't be overcharged on prescriptions. For once this is a good law to come out of our legislators and hopefully other state will/have followed. Limit on Prescription Costs November 13, 2018 On Sept. 26, 2018, Gov. Brown signed AB 2863 into law. The new law, effective Jan. 1, 2019, limits the amount that a health plan participant will pay for a covered prescription at the point of sale at the pharmacy. Specifically, a participant will pay the applicable cost-sharing amount (copayment or coinsurance) or the retail price, whichever is less. A participant cannot be required to pay a cost-sharing amount that exceeds the retail price.

In our State, you have to specifically ask if there is a cheaper way, like " is this prescription cheaper if I just pay cash ?" .

There is some agreement/contract that forbids the pharmacist from giving or OFFERING a person the cheapest way unless requested.

[RetireBy90]

Our Kaiser plan requires $10 for prescriptions but I did take one to a local Giant pharmacy one time and only paid $3 or so for the drugs. I did tell them I had Kaiser and showed my card, so they may have had some agreement in VA at the time.

[RetiredAndLovingIt]

Yes, apparently this has been a legal consumer rip off for years until recent Patient right to know laws have been passed. The pharmacist had to sign a gag order and then the middlemen clawed back the overpayment between the copay and actual cost.

PBM Legislation - PBM WATCH