GoodRX and Part D

Here's an article describing practices that create at least part of the problem being discussed here....

https://www.nbcnews.com/health/heal...surance-be-costing-you-money-pharmacy-n811171

As consumers I've learned that we just need to look at medical pricing as a game at least for the time being. Asking for cash price (without insurance) and using Good Rx and similar "coupons" (without insurance) are a couple of ways to do this. My wife and I have been doing it ever since going on Obamacare (I am now on Medicare). When I went to get my first Shingrix vaccination I found that my Medicare drug plan doesn't cover it so I used a Good Rx coupon for a lower price.

My wife used to smoke so she wanted to get a heart CT scan and calcium score to assess her risk. By shopping around we found a respected local hospital offering the service for a cash price of $99 including interpretation of the test (scoring). It's surprising how much a person can save by "shopping" (usually via the internet) especially when dealing with very high deductible insurance plans but obviously in other circumstances as has been discussed in this thread.
 
Here's an article describing practices that create at least part of the problem being discussed here....

https://www.nbcnews.com/health/heal...surance-be-costing-you-money-pharmacy-n811171

As consumers I've learned that we just need to look at medical pricing as a game at least for the time being. Asking for cash price (without insurance) and using Good Rx and similar "coupons" (without insurance) are a couple of ways to do this. My wife and I have been doing it ever since going on Obamacare (I am now on Medicare). When I went to get my first Shingrix vaccination I found that my Medicare drug plan wouldn't cover it (high deductible because I take no maintenance drugs) so I used a Good Rx coupon for a lower price.

My wife used to smoke so she wanted to get a heart CT scan and calcium score to assess her risk. By shopping around we found a respected local hospital offering the service for a cash price of $99 including interpretation of the test (scoring). She's received substantial discounts on other tests simply by asking for the cash price.

It's surprising how much a person can save by "shopping" (usually via the internet) especially when dealing with high deductible insurance plans.
 
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travelover said:
Interesting discussion. I find it somewhat humorous that pharmacies / drug companies are charging outrageous prices as show by the price variance, yet consumers trying to minimize their costs are the "bad guys". Just be transparent so we can shop drugs like anything else. You can't have it both ways. :mad:
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+1

A few years ago I was told by my local pharmacy a particular drug was taken off the market by the FDA. There was nothing similar other than stepping up to very strong opioids.

After a long convoluted series of discussions I learned the drug wasn't taken off the market. The pharmacy decided they were losing money providing it to me at the agreed price. I remember the discussion with the pharmacist when I confronted her... "well I hope you are not mad at me...." really kid I've had a cluster headache for a week because of your stupidity? Be glad it's not legal to...
 
nwsteve said:
I had nice chat with a senior tech who told me that it has been a long standing policy by Medicare to disallow discount/coupons for anyone who has Plan D. Her explanation was not nearly as complete as yours but she did say Costco had just began enforcing it in their system.
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I believe the tech you spoke with was even a little confused on the matter. I can assure you that at any time you can request that your prescription can be filled off of insurance (any commercial or medicare part D program) and a discount like GoodRx or Lowest Price Med can be used in its place, it is just highly discouraged and must be documented by the pharmacy that it is being requested. This is due to the mess of DIR fees that I had mentioned.

What has always been the case is if you have medicare part d (and other government plans, including Tri-Care, federal blue cross, etc.) you cannot use a coupon in conjunction with or instead of your insurance. These are those co-pay cards that you might see offered on TV while the drug is being advertised "pay no more than $30* per month for the first 12 months of your prescription for Eliquis". What the dr office or person watching the commercial doesn't know is that little asterisk notes is that the coupon/copay card doesn't work with federal plans and/or has a maximum payout of $100 towards the $400 medication.

What Costco has is called the CMPP (Costco Member Prescription Plan) which came out during the hub bub of the $4 WalMart list, the Walgreens Prescription Savings Club, etc. about 10 years ago. It is a plan that is free if you are a Costco member and didn't have insurance. It would save you on average of $3-5 off cash scripts per 30 day supply.

10 years ago there wasn't an issue of DIR fees, but there was a huge thing with medicare part D called the doughnut hole or coverage gap where you would have to pay 100% out of pocket when you hit $xx,xxx amount of benefit and it would take $x,xxx to get to the other side of said doughnut hole, where coverage would pick up again. At that time people would rather buy their cheapest medications with cash on the CMPP which would help them not hit the doughnut hole as fast or at all and the restriction that Costco had of not being able to use CMPP if you had insurance had been adjusted to if the insurance wasn't paying for the prescription you could use CMPP.
That has since been tightened up and CMPP cannot be used anymore with anyone who has medicare part D period, which is what I believe the tech you spoke with was referring too.

Fast forward to today and the doughnut hole is not 100% out of pocket but has been shrinking to a max of 25% by 2020 https://q1medicare.com/q1group/MedicareAdvantagePartDQA/FAQ.php?faq=Will-the-Coverage-Gap-or-Donut-Hole-eventually-close-and-just-go-away-&faq_id=471&category_id=118

nwsteve said:
Ronnieboy--forgot to ask you what are "DIR fees"?
thx
Click to expand...

Hard to explain but what DIR stands for is 'direct and indirect remuneration' a pull back on what a pharmacy benefits management company (PBM) has paid a pharmacy after it has already dispensed the medication. Here are a couple of boring articles: :LOL:

https://www.specialtypharmacytimes.com/news/do-dir-fees-stand-a-chance-in-2018

http://www.drugtopics.com/blog/dir-fees-just-one-many-reimbursement-battles

But the basic idea is that a prescription is processed through your aetna medicare part D plan. Lets say it is for 30 days of metformin 500mg at one a day, a popular diabetes medication. The claim is processed online and as a pharmacy you are submitting which drug it is, the quantity of medication, how many days it is supposed to last the patient and a host of other stuff, one of which is the pharmacies usual and customary price for the prescription which is the term used if John Doe came in the pharmacy without insurance and said I want some metformin 500mg #30 cash please.

Lets say that your generic copay through Aetna is $5 for 30 days so no matter what you are only going to pay $5. Whatever your insurer is going to pay - lets say its $10 towards the claim - it is only going to cut a check to the pharmacy every 30 days for the past 30 days of claims so as a pharmacy you are waiting up to 60 days to get paid for a drug that left your pharmacy two months ago.

But lets go back and see what two retail pharmacies would submit for the claim of metformin 500mg #30 tabs. (these are hypothetical numbers)

WalMart submits all the info and says we want $35 for the script but our usual and customary charge for this is $4 because it is on our $4 list.

Walgreens says we want $120 for this because our usual and customary is $120 for the medication.

Aetna send back to Walmart: charge our member $4 because that is what your cash price is and we are sending you $0

Aetna send back to Walgreens: charge our member $5 because that is what his copay is and were going to send you $10 because that is all you are allowed to get for #30 metformin 500mg tablets. So walgreens gets $15 total and Walmart gets $4.

Now DIR fees come into the picture when Aetna says well you should be processing the patients prescription of metformin for 90 days instead of 30 because that increases compliance, negative mark. Based on the number of diabetic prescriptions for your whole chain we can see only a 60% compliance rate on refills so that is another negative mark. When all is said and done we are taking back (or basically withholding future payment of any other aetna insurance payments) $6 for the prescription. If you are walmart you just lost $2 for the script that you only received $4 for in the first place.

This is one reason why you see or read about these news stories when reporters are doing price comparisons and they show you the shocking price of some generic drug at Walgreens is $150 more than the lowest price from another pharmacy. Walgreens can max out the contract price of all drugs through the insurance because their usual and customary is out of this world high and typically always above a contracted price.
 
Ronnieboy said:
What has always been the case is if you have medicare part d (and other government plans, including Tri-Care, federal blue cross, etc.) you cannot use a coupon in conjunction with or instead of your insurance. These are those co-pay cards that you might see offered on TV while the drug is being advertised "pay no more than $30* per month for the first 12 months of your prescription for Eliquis". What the dr office or person watching the commercial doesn't know is that little asterisk notes is that the coupon/copay card doesn't work with federal plans and/or has a maximum payout of $100 towards the $400 medication.
Click to expand...

Having said that there are coupon cards directly from the manufacturer and usually available either online (at the drug website) or from doctors offices that do allow a one month supply free specifically for medciare/government plans. Usually processed with the coupon card only and no other third party involvement.
 
travelover said:
Interesting discussion. I find it somewhat humorous that pharmacies / drug companies are charging outrageous prices as show by the price variance, yet consumers trying to minimize their costs are the "bad guys". Just be transparent so we can shop drugs like anything else. You can't have it both ways. :mad:
Click to expand...

I whole-heartedly agree. It has unfortunately become a game of which hoops to jump through and the consumer is the biggest loser.
 
PBS had a segment on this topic tonight.
https://www.pbs.org/newshour/show/do-prescription-drug-middlemen-help-keep-prices-high




Americans pay more for prescription drugs than any country in the world, and the pharmaceutical industry earns billions in profits each year. Critics blame pharmacy benefit managers, or PBMs, for a portion of those high costs through their role as middlemen between insurance plans, drug makers and pharmacies—but PBMs say they save consumers money. NewsHour Weekend Megan Thompson reports.
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Yeah, my insurance really saves me money on prescriptions. Using my insurance the cost was $75 for a 90 day supply. Using WellRx costs $11 for a 90 day supply. At the same pharmacy. :banghead:
 
Ronnieboy said:
I have also never heard of a limit on printed prescriptions, unless it was a controlled substance :confused:
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Nope, it was a cheap generic blood pressure drug, Losartan 25mg 90 day. I knew I had plenty at home and didn't want to refill it just yet so I asked for a printed Rx so I could mail it in when I needed it.
 
I'll tell you what would get rid of all this crap, fictional pricing, jockying money around to even things out after the fact...all of it would be gone overnight if Amazon or somebody (everybody) could buy internationally. The drugs could still be made in the same factories, most of which are not in the states anyway, but the American consumers wouldn't be the patsy at the prescription drug poker table.
 
Ronnieboy said:
This will be interesting to see.

Will Amazon have the same issues that mail order pharmacies have now?

How much will it change the price of already expensive drugs? If it costs $450 to buy #30 Xarelto 10mg from Janssen pharmaceuticals how can they get it lower?
Click to expand...

Good questions. Drugs under patent may not be affected much. And many generics are already available for around $10 from Walmart, etc. But there are many drugs that are not under patent, and not on the cheap generic list, but are in a price obfuscation hell. Amazon can solve this, and they are really good at doing that. I have a dream of these prescription drugs being available by Amazon prime, where you can buy with confidence that you're not being ripped off- you probably can't find it much cheaper elsewhere, and you don't have to play games with pharmacies who try to charge 10X or 20X as much as they should. And since this situation mostly applies to the uninsured and elderly, I think pharmacies deserve to be taken to the woodshed (figuratively, of course, for their market share) for what they are doing. So, Go Amazon!
 
As long as we're "commenting" on the state of things...


Have you ever tried to get the price of one of these "price obfuscation hell" drugs before you bought the health insurance policy? Luckily, I take zero Rx now, but I used to take a pill every day, and the lovely pharma company reformulated it with a different coating to extend the patent. So it was expensive. Shopping for a high deductible policy meant that the price was important; I'd be paying every cent until I hit $6,500 (which I probably would not hit). But no matter how many calls I made, I could not find out from any HI provider or pharmacy how much I would be charged for this drug. That's criminal. Impossible to compare HI plans if the highest cost expected spending item price is blocked from view.
 
I just refilled three prescriptions using GoodRX coupons, rather than using my Part D drug plan. Cost for a 90 day supply for these three drugs was $117. Cost under my Part D Plan would have been around $320. A nice $200 savings in my pocket. It’s hard for me to understand why my Part D plan has such crappy coverage.
 
txtig said:
I just refilled three prescriptions using GoodRX coupons, rather than using my Part D drug plan. Cost for a 90 day supply for these three drugs was $117. Cost under my Part D Plan would have been around $320. A nice $200 savings in my pocket. It’s hard for me to understand why my Part D plan has such crappy coverage.
Click to expand...

Which state and which company, if you don't mind sharing?

I assume you went to a different pharmacy and told them you did not have coverage. To the insurance company, you will look like an uncooperative patient, not taking your prescribed drugs. That could have repercussions.
 
txtig said:
I just refilled three prescriptions using GoodRX coupons, rather than using my Part D drug plan. Cost for a 90 day supply for these three drugs was $117. Cost under my Part D Plan would have been around $320. A nice $200 savings in my pocket. It’s hard for me to understand why my Part D plan has such crappy coverage.
Click to expand...

It's the payment schedule your plan negotiated with the pharmacy benefit manager. Generally when drug prices are that high, you have a low $ premium, OR, the drug store is not on the preferred list for the Part D plan, and you're paying for the convenience of using that particular store.

All the druggist gets is a dispensing fee (about $2), the PBM contracts with a smaller number of chains. The PBM orders the drug and supplies it to the chains. By restricting the number of chains they supply, they get volume discounts from the wholesaler who delivers to the chain for dispensing.

I hope that's clear.

The cost of drugs at GoodRx.com are what the local drug chains choose to charge those without insurance. It's cheaper (no electronic connection to the plan to check coverage, no contracting, etc.) because they fill more prescriptions and keep their admin costs low. Higher volume leads to lower wholesale cost of the drugs they buy from the manufacturers because of the volume.

So it is good to compare GoodRx to Part D plans. They are both doing the same thing, trying to get the lowest price on common drugs by increasing the volumes in order to negotiate prices.
 
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Another Reader said:
Which state and which company, if you don't mind sharing?

I assume you went to a different pharmacy and told them you did not have coverage. To the insurance company, you will look like an uncooperative patient, not taking your prescribed drugs. That could have repercussions.
Click to expand...

Repercussions like what...obviously you don't have to use your insurance to pay for meds
 
Someone recently posted here about how the "system" works. I can't find it right now unfortunately. There are multiple players, pharmacies, PBM's and insurance companies. Pharmacies are penalized if you don't purchase the prescribed medicine at the refill time. The assumption is that patient is not taking the medicine. The PBM and the insurance company don't know you used Good RX somewhere else for a better price. Have you noticed recently that your doctor asks which pharmacy you use and sends the prescription directly to them? Try to get a written scrip from a doctor. A lot are not allowed by their employer to give it to you. If the pharmacy has your prescription and your insurance information, often they won't sell you the prescription except through insurance. They lose money if you don't buy it through the insurance/PBM.
 
Another Reader said:
......... Try to get a written scrip from a doctor. A lot are not allowed by their employer to give it to you. If the pharmacy has your prescription and your insurance information, often they won't sell you the prescription except through insurance. They lose money if you don't buy it through the insurance/PBM.
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This is true, but I'm fairly certain that you can have the prescription transferred to another pharmacy. It is an inconvenience, though.
 
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Another Reader said:
Someone recently posted here about how the "system" works. I can't find it right now unfortunately. There are multiple players, pharmacies, PBM's and insurance companies. Pharmacies are penalized if you don't purchase the prescribed medicine at the refill time. The assumption is that patient is not taking the medicine. The PBM and the insurance company don't know you used Good RX somewhere else for a better price. Have you noticed recently that your doctor asks which pharmacy you use and sends the prescription directly to them? Try to get a written scrip from a doctor. A lot are not allowed by their employer to give it to you. If the pharmacy has your prescription and your insurance information, often they won't sell you the prescription except through insurance. They lose money if you don't buy it through the insurance/PBM.
Click to expand...

that makes no sense,what control does the pharmacy have over you taking your meds.my national pharmacy chain has no problems with using either good R X
or insurance whichever is cheapest.
 
Another Reader said:
Which state and which company, if you don't mind sharing?



I assume you went to a different pharmacy and told them you did not have coverage. To the insurance company, you will look like an uncooperative patient, not taking your prescribed drugs. That could have repercussions.
Click to expand...



I’m in Texas and my Part D provider is Aetna. I have been ordering 90 day supplies of my meds directly from Aetna using their mail-order plan. I thought that would be most cost effective. But, the cost of my meds through Aetna is about triple of what I was paying through my former private insurance plan (I just went on Medicare this year).

I checked the price of my meds on the GoodRX site and noticed the big difference. I asked my doctor’s office to send a new prescription to the drug store I wanted to use. I had never used this store before, so they did not have any insurance info on me. When I picked up the meds, the pharmacist asked me for my insurance info. I simply handed her the GoodRX coupons. She them processed the payments to with no further questions.

I don’t think that my Part D plan is a low premium, bare bones plan. I used an online tool to select them based on the meds I’m currently taking. I still have a hard time understanding why a plan that I have to pay for is much more expensive than using free coupons available on the internet. It almost seems like the insurance company is making a profit by selling me these meds rather than defraying my costs.
 
txtig said:
I don’t think that my Part D plan is a low premium, bare bones plan. I used an online tool to select them based on the meds I’m currently taking. I still have a hard time understanding why a plan that I have to pay for is much more expensive than using free coupons available on the internet. It almost seems like the insurance company is making a profit by selling me these meds rather than defraying my costs.
Click to expand...

There is definitely some funny business going on.

It may have something to do with pharmacy benefit managers and rebates.
https://www.pbs.org/newshour/health/why-a-patient-paid-a-285-copay-for-a-40-drug
 
ivinsfan said:
that makes no sense,what control does the pharmacy have over you taking your meds.my national pharmacy chain has no problems with using either good R X
or insurance whichever is cheapest.
Click to expand...
I agree it makes no sense, but apparently it is true. Read post #14 in this thread.
 
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