Drugh Prices Revisited

[OldGranddad]

In my last post, I told that Costco sells a drug for $21.69 cash that I had an $80.00 co-pay for at Safeway. I was unable to deal with Costco due to their idiotic policies. Instead,I found the Sebastopol Family Pharmacy that sells the drug for $38.76 cash. The amazing thing is that if I use my insurance to buy it, the price to me is $57.17.

In my humble opinion, that is not insurance. It is just plain stealing. I went on the warpath and contacted Medicare Fraud, the Press Democrat, The SF Chronicle and Senator Dianne Feinstein's office. Apparently , none of them agree with me as I never received a reply from any of them.

Am I crazy or am I just living in a giant insane asylum where everyone else is?

Old Granddad

[Asa]

Cash prices vary wildly.

I would call your insurance company to clarify if you don't know—but I suspect you have an annual deductible and haven't met your deductible yet. It's an open secret that most insurance plans rip you off during the deductible period and actually profit from your out of pocket payments. Pharmacies are usually prohibited by contract to tell you that they can charge you less, unless you ask.

This is a scandal and should indeed be illegal, but as far as I can tell, it's standard practice.

Also, there are lots of free pharmacy "discount cards" that enable you to pay much less than the so-called cash price. Some pharmacies might be in the habit of applying one for you. But each discount card/code offers different prices for different medications, so one discount card/code might give you a lower price for one medication than another card, but a higher price for a different medication. If you gather some of these discount codes or ask the pharmacy if they have any, you can ask them to compare prices for you, if they're not too busy.

The County of Sonoma distributes one labeled "Sonoma County Rx". I think I got it at a table at a farmer's market a few years back. Another one I currently have is called "Good Rx"—I think a pharmacy gave me that one. Sometimes insurances plans will issue a discount card to you in addition to your insurance card, intended for use with medications they don't cover at all (though you can also appeal for insurance coverage or for getting a medication at a lower price tier with your insurance company). If the medication is not available as a generic, and you have trouble affording it, most drug manufacturers also have assistance programs, where you basically sign a piece of paper saying you can't afford it, and your doctor signs it too and submits it with a prescription to the manufacturer. Typically. And then typically they give you the drug for free, in my experience.

The problem with not using your actual insurance during your deductible period is they can't automatically track your spending, so you never meet your deductible and thus the insurance will never start helping you. There is a solution, but it's a hassle. You do have the right to pay cash (discount cards are also like cash, as they are not insurance), and then keep your detailed receipts showing the actual prescriptions. And ask your insurance company how to submit them for proof of out of pocket costs. There should be a process. I have never taken the trouble to do all that.

These days I either pay the rip-off copay until my deductible is met, or I contact the manufacturer for free product. If I needed a very expensive generic I would take the trouble to go the third way outlined above, but I have not yet.

[OldGranddad]

I take 13 prescriptions every day. Let me assure you that I met my deductible a long time ago. In fact, it was with my first monthly purchase of drugs in January of this year. In addition, I purchase 2 of the 13 in Canada for far less than I can get them with my insurance here. Also, I'm aware of GoodRX.com, but haven't used it yet.

While I'm happy with Medicare A & B, Part D stinks. In my opinion it's just a conspiracy to defraud all who are on it.

Old Granddad

[Asa]

I hear you. I'm a little more positive about it, as I too am on Part D, and for me, it does save me money. It sounds like you have crippling drug costs though, and it's not working as well for you.

I have noticed that the premiums on Part D plans have gone up a lot over the years, and that getting coverage for certain medications has become harder. But I understand that 2019 plan premiums are generally going down substantially.

It's worthwhile to do a plan comparison on Medicare's site while we're still in this open enrollment (I haven't done it yet)... As you probably know, it can estimate your annual cost for your specific drugs.
Also, if your income is relatively low, you might qualify for "Extra Help with prescription drug costs". You request that from Medicare if I recall, though it's a state-managed thing. Depending on your income, you get different degrees of help. At maximum assistance, I think it pays your Part D premium, deductible, and copays. At a minimum, if you qualify, it reduces your deductible and premiums, and limits your copays to a maximum of 2%—I think—of the negotiated drug price.

Then yet another thing you can do. Check the prices for your prescription drug plan's mail-order pharmacy. Mine provides many generic drugs at no cost even during your deductible period. I think that's just for the lowest-priced drug tier. But still, they might undercut even in-network pharmacy prices. Might be worth checking if you haven't.

An interesting thing about drug pricing when paid with insurance that I've noticed is that it usually is based on a set price for a number of days supply—regardless of dose or number of tablets, so if your prescription says "take 1 to 4 tablets daily as needed", the number of days is based on taking 4 tablets daily. If you typically take 2, your cost once your deductible is met will usually be half what it would be if your prescription said "take 2 tablets daily" (the first prescription would be for up to 120 tablets a month, the second for 60—but the charge would be the same).

If you've met your deductible, and you go to an "in-network" pharmacy, it's my impression that the price you pay will be the the same as at other in-network pharmacies and should be lower than most other pharmacies. In-network pharmacies make a contract to sell you the drugs at a set, usually lower, price when you use your insurance.

I'm pretty sure that with all Part D plans (and with Medi-Cal for anyone on that)—if not other plans too—you can request that they offer you a drug in a lower priced tier based on your ability to pay. I don't recall them asking for evidence or income or anything like that when I did it in the past. The policy always seemed to be that they would knock a drug down one tier for you (and one only), which for some drugs doesn't make a big enough difference, but sometimes does make a big difference. For medications not on the plan at all, they can put it on the most expensive tier for you if your doctor establishes medical necessity (I.e., the drug is approved for your use case and you've tried other drugs they do cover).

And seriously, if you take any brand name prescription drugs, contact the manufacturer (or their website) and ask about assistance programs to get them for free... or at least low cost... directly from them/their partner mail order dispenser. You could also talk to you doctor about switching to an expensive brand name drug from an expensive generic in order to take advantage of an assistance program on the brand drug. Ironically.


Currently, my main problem is that I haven't found a drug plan in several years that will cover a particular medication that I need. It's a covered drug, but only with prior authorization and proof you have a specific on-label condition. I need it for an off-label use that definitely is effective and there's no alternative to. It might be possible to appeal the denials I've gotten and get coverage for it like I did until a few years ago, but I haven't taken it that far. That's been rather frustrating. I need to get it together to compare plans ASAP though... Maybe another Part D plan has it without the prior authorization restriction this year.


Good luck. This is all much more difficult than it should be, and aspects of how drugs are sold and priced are definitely scandalous—both when insurance is involved and when paying cash.

[wisewomn]

Such is the political clout of Big Pharma. :-(

I take 13 prescriptions every day. Let me assure you that I met my deductible a long time ago. In fact, it was with my first monthly purchase of drugs in January of this year. In addition, I purchase 2 of the 13 in Canada for far less than I can get them with my insurance here. Also, I'm aware of GoodRX.com, but haven't used it yet.

While I'm happy with Medicare A & B, Part D stinks. In my opinion it's just a conspiracy to defraud all who are on it.

Old Granddad

[rossmen]

I think your assessment of our drug-addled society is accurate. My free advice is to try to cut back on your pharmaceutical use. I have found that legal drugs are very powerful and dangerous, even more so than self-prescribed ones, and simple herbs, whole food, and life choices far more efficacious for health.

...In my humble opinion, that is not insurance. It is just plain stealing...

[Dorothy Friberg]

No, you are NOT crazy, I have similar problems with my auto insurance. Last time I had a fender bender with a driver backing out on to a state highway, his insurance claimed that I was 30% at fault for not avoiding HIM even though that particular section of road was lined with trash pickup barrels (the big ones) making visibility nearly impossible on the backer's side.
Face it, Grandad, they've got us by the short hairs and they will extract as much money from our poor holey pockets as they can on both ends. Pretty soon you will be charged for pooping said meds into the waste stream.

In my last post, I told that Costco sells a drug for $21.69 cash that I had an $80.00 co-pay for at Safeway. ...

In my humble opinion, that is not insurance. It is just plain stealing...

Am I crazy or am I just living in a giant insane asylum where everyone else is?

[patnicholson]

Do not allow them to ignore you. Send follow-up emails and start calling them. Get names of the people you talk to. Have you considered one of the tv news hotlines?

See if you can find and contact advocacy groups . Other folks are in the same boat you are.

persistence, and patience

...In my humble opinion, that is not insurance. It is just plain stealing. I went on the warpath and contacted Medicare Fraud, the Press Democrat, The SF Chronicle and Senator Dianne Feinstein's office. Apparently , none of them agree with me as I never received a reply from any of them....

[Sara S]

I've been getting my drugs at Lark Drugs in Guerneville for 30-40 years, and even though I live in Sebastopol now, I still went there until they opened a second location: Sebastopol Family Pharmacy. Their service has always been terrific and the staff is excellent. Good parking here, too!

Auntie Wacco