Prescription copay vs Direct payment

[Ready]

I picked up two prescriptions at Costco today. In both cases the pharmacist told me it was cheaper to pay the Costco direct price than the copay on my insurance. This has happened to me several times now. Which leads me to wonder what the purpose of my prescription insurance is.

Both of my prescriptions were generic, which likely had something to do with it. Is prescription insurance now only for exotic prescriptions that can’t be purchased generically?

 

[disneysteve]

Which leads me to wonder what the purpose of my prescription insurance is.

Your insurance is for prescriptions that cost more than your copay.


The vast majority of prescriptions (about 90%) are for generics today, though even generics can be costly. You're fortunate that yours are not.

 

[Dash man]

Most of my prescriptions are zero copay, but a couple are cheaper using GoodRx.

 

[audreyh1]

I picked up two prescriptions at Costco today. In both cases the pharmacist told me it was cheaper to pay the Costco direct price than the copay on my insurance. This has happened to me several times now. Which leads me to wonder what the purpose of my prescription insurance is.

Both of my prescriptions were generic, which likely had something to do with it. Is prescription insurance now only for exotic prescriptions that can’t be purchased generically?

I’m impressed that Costco provided this service.

For me, prescription insurance is for in case of ongoing expensive drugs. I don’t sweat the cheap stuff.

By not using the insurance and paying the copay, it’s not applied against the annual deductible, but again that only helps if you have ongoing expensive drugs.

 

[Sunset]

If they are really cheap, it doesn't matter.
We just got some drugs and it was ~$2.50 for two prescriptions.

However, if the cost is more than a few dollars, one does need to think about the annual deductible.

In theory if a person has a low annual deductible that they normally hit every year, it would be better to pay a few extra dollars to have the cost count against the deductible if the drug cost was over $20 either way.

 

[Ready]

I checked the pricing with Amazon’s pharmacy out of curiosity. The Amazon direct price for my subscription is $36.50. The copay with my insurance is $60.00.

The Amazon price was within $1 of the Costco price. So it seems my prescription plan is just not that great, at least for the prescriptions I’m looking at.

 

[MC Rider]

My 2 things are about $6 a month if I go to the pharmacy around the corner.
Or I could mail order a 3 month supply, but it costs more that way.
I'll keep walking to the pharmacy once a month.

 

[RetiredAndLovingIt]

I checked the pricing with Amazon’s pharmacy out of curiosity. The Amazon direct price for my subscription is $36.50. The copay with my insurance is $60.00.

The Amazon price was within $1 of the Costco price. So it seems my prescription plan is just not that great, at least for the prescriptions I’m looking at.

It's a California law that Jerry Brown signed AB2863 effective 2019 or 2020 that ensures that consumers will pay the lesser of their copay or the cash prices for prescription drugs. I remember getting documentation from Blue Shield stating the change and my kaiser drug pricing is always less than my copay.

 

[RetiredAndLovingIt]

Here's the back story behind it. Some states have enacted laws similar to California to prohibit the practice but many have not. While it's legal, it's also total greed not to share the lower retail price and have the pharmacy return the overpay back to the insurance company. So the moral of the story is always ask what the non insurance price is for your prescriptions if you state has not enacted a clawback law.

https://abcnews.go.com/Health/overpay-prescriptions-pays-higher-drug-prices-study/story?id=53767651

http://www.ncpa.co/pdf/2019-state-legislative-wins-com-pharm.pdf

 

[Scuba]

For those with a high deductible, you may want to also ask about the cash price for lab work, X rays, MRI’s, etc. The cash price is usually substantially lower than my bill if it’s run through insurance.

 

[Go Bolts]

I picked up two prescriptions at Costco today. In both cases the pharmacist told me it was cheaper to pay the Costco direct price than the copay on my insurance. This has happened to me several times now. Which leads me to wonder what the purpose of my prescription insurance is.



Both of my prescriptions were generic, which likely had something to do with it. Is prescription insurance now only for exotic prescriptions that can’t be purchased generically?

The purpose of your insurance is to enrich the carrier.

Using GoodRx and being a savvy consumer is to enrich yourself.

It’s a big game. Try to be the pigeon more often than the statue.

Kudos to your pharmacist for helping you without you having to ask. [emoji106]

 

[harllee]

Do any of you take really expensive medications? DH take Humira which without insurance runs about $10,000 per month. DH is on Medicare and has Part D insurance so he gets s help but it is still very expensive. We do not qualify for the Humira Foundation help because our income is too high (the income limit is $80,000 per year.) Using GoodRX, the cost is still $6000 per month. We have not figured out a way to get it from Canada.

 

[Ready]

Do any of you take really expensive medications? DH take Humira which without insurance runs about $10,000 per month. DH is on Medicare and has Part D insurance so he gets s help but it is still very expensive. We do not qualify for the Humira Foundation help because our income is too high (the income limit is $80,000 per year.) Using GoodRX, the cost is still $6000 per month. We have not figured out a way to get it from Canada.

How can the average Medicare patient afford $6,000 per month for medication? If you make $85,000 per year and spend $60,000 on meds, you hardly have anything left to pay your bills.

 

[Golden sunsets]

Do any of you take really expensive medications? DH take Humira which without insurance runs about $10,000 per month. DH is on Medicare and has Part D insurance so he gets s help but it is still very expensive. We do not qualify for the Humira Foundation help because our income is too high (the income limit is $80,000 per year.) Using GoodRX, the cost is still $6000 per month. We have not figured out a way to get it from Canada.

Wow Harlee; That's a crazy amount.

 

[harllee]

DH does not pay $60,000 for the Humira. That is what someone with no insurance pays. Since DH is on Medicare and has Part D prescription coverage he immediately goes in the donut hole and "only" pays about $7000 per year for Humira. It is very expensive but it is a miracle drug for him, it has given him back his life. DH has psoriatic arthritis, an autoimmune disease and would most likely be unable to walk without Humira (he might even be dead without Humira). I do get mad--the patent has run out on Humira so there should be generics but the manufacturer (AbbieV) has somehow gone to court and blocked the generics. Humira is the world's best selling drug--it is used for many autoimmune diseases and is really a miracle drug. It is given by injection--DH gives himself a shot every other week.

 

[MC Rider]

The way they price gouge on drugs like that is criminal, or should be.

 

[CardsFan]

The way they price gouge on drugs like that is criminal, or should be.

Would you rather they not spend the money to develop drugs? Manufacturing costs are not the driver for pricing, development costs are. And most ideas do not make it to market. They have to cover ALL the development costs, not just the ones that make money.

I am not here to defend Big Pharma, and never worked in the industry. But in many ways it is no different than electronics. Early adopters pay big bucks, 10 years later, it is cheap.

Of course, I know, with drugs the choice to buy is not optional.

Just MHO.

 

[MC Rider]

Would you rather they not spend the money to develop drugs? Manufacturing costs are not the driver for pricing, development costs are. And most ideas do not make it to market. They have to cover ALL the development costs, not just the ones that make money.

I am not here to defend Big Pharma, and never worked in the industry. But in many ways it is no different than electronics. Early adopters pay big bucks, 10 years later, it is cheap.

Of course, I know, with drugs the choice to buy is not optional.

Just MHO.

I get that they need to make money. Good money, not just a little.

But when they want to charge $700 a pill........


Or whatever is the number on the latest scandal / Covid pill.


It just displays their heartlessness for all to see.

 

[travelover]

Would you rather they not spend the money to develop drugs? ........

False choice, straight out of Big Pharmas playbook. We never agreed to pay for all the development costs for the whole rest of the world, that buys drugs at a fraction of the price we pay.

 

[OldShooter]

... Manufacturing costs are not the driver for pricing, development costs are. ...

Another thought out of the playbook, I think. I have read that the driver is sales and marketing costs, which exceed development costs.

That said, the cost of paying off Congress has to be a big factor too.

 

[harllee]

I agree that drug companies should make a profit on the drugs they develop. That is why the US gives the companies a 20 year patent. But after that patent runs out there should be generics. I just don't understand why Abbvie, the manufacturer of Humira has been able to stop generics. The Humira patent ran out in 2018 and since then Abbvie has continued to be successful in stopping Humira generics. It is a racket.

 

[Scuba]

I agree that drug companies should make a profit on the drugs they develop. That is why the US gives the companies a 20 year patent. But after that patent runs out there should be generics. I just don't understand why Abbvie, the manufacturer of Humira has been able to stop generics. The Humira patent ran out in 2018 and since then Abbvie has continued to be successful in stopping Humira generics. It is a racket.

Is it not possible to get this drug in Mexico?

 

[RetiredHappy]

Do any of you take really expensive medications? DH take Humira which without insurance runs about $10,000 per month. DH is on Medicare and has Part D insurance so he gets s help but it is still very expensive. We do not qualify for the Humira Foundation help because our income is too high (the income limit is $80,000 per year.) Using GoodRX, the cost is still $6000 per month. We have not figured out a way to get it from Canada.

I don't know the details but our close friend (wife) managed to get Humira to help with payment of the drugs. I think they said their household income is around $110K. Their SS is about 65K and have an annuity which pays $45K a year. I know they were initially declined but was successful in their appeal. They submitted all of their medical costs - cataract surgery etc to show how much they were spending on medical stuff.

 

[harllee]

Is it not possible to get this drug in Mexico?

Do you have a mail order pharmacy in Mexico you trust? The problem with Humira is that it is an injectable and has to be kept on ice when delivered.

 

[CRLLS]

Meanwhile, the NIH helps to pay universities and drug companies for research. How is it we, the US taxpayers, get our share of those investments? It seems to be just a bit out of balance WRT drug prices in other prices, either under patent or not.

OTOH what about drugs developed in other countries and sold in the USA? There must be some. Are those prices similarly priced unfavorably in the USA? I don't know.