A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

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cresive
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A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by cresive » Sat Nov 16, 2019 10:04 am

This is a true story of our [confusing -- mod oldcomputerguy] Medical System!!

At the risk of having another post removed, I think this needs to be said! This is not a post for medical advice, but to alert our community of how complex paying for medicines can be. This is a tale of a good friend of mine who literally saved thousands of dollars by walking 50 feet down a parking lot.

Background:
53 y.o. male who has had a career as a senior banking official, but who is dealing with being downsized after his bank was bought and he was made redundant. His insurance is a COBRA extension of his employment policy. He takes several medications that range in price from $10 to $600/month each.

Here is where the story gets interesting: Since he is unemployed he has to watch how he spends his severance and savings. This has created some difficult decisions and he has a hard time justifying purchasing a few of his medications, especially the expensive ones. He did try to go without them or substitute some OTC medications, but that was not an option as it left him unable to function. I helped where I could, and informed him that his Dr. may have some drug samples that could tie him over until he could get his prescriptions filled. He did manage to get a few weeks-worth of meds this way.

He used a local drug store to fill and monitor his prescriptions. After a while, he began to pay cash as it was cheaper than using his insurance, due to the pricing schema being different with a 3rd party paying. To help with costs, he bought an App to enable him to comparison shop. He found that using the pharmacy in the grocery story (LITERALLY NEXT DOOR) could save him a couple dollars so he moved a few prescriptions there and paid cash. He eventually moved his essential prescriptions to the grocery store and went to pay cash for his prescriptions after his experience with paying cash at the drug store. The new pharmacist talked him into checking how much his insurance would pay to ensure that paying cash was the best way to go. Low and behold! he found out that not only did he save a few dollars, but his insurance paid for the entire LOT! He would have never realized this, as he was going to pay cash, but the pharmacist convinced him to run his insurance through his service. Instead of paying $75 for the prescriptions (two total drugs), he walked out of there without paying a dime!

Perplexed I helped him investigate why the drugs were paid by the insurance company, seemingly all of a sudden, and low and behold the grocery store was a "Preferred" Pharmacy, whereas the drug store next door was not. Apparently, there was some fine print in his policy--which the insurer acknowledged was in a section that nobody reads-- identifying certain pharmacies as preferred. The benefit of going to a preferred pharmacy was only that there was better coverage, not total coverage. I guess this is analogous to in-network/out of network care givers, but I never realized this was a thing with pharmacies.

The upside, is that I am taking my friend to get ALL his prescriptions filled, today! I wanted to post this message to remind everyone to read the fine print--it could save you thousands!!!! I only wish we knew this before my friend wasted over a thousand dollars of his severance on medications--not to mention the thousands he lost while he was employed and didn't realize the cost of not comparison shopping pharmacies.

Ben

PS. I am literally holding back a LOT of rage about how screwed up this system is so that the post will remain up! If you had witnessed the agony my friend has been going through because he couldn't afford to fill all of his prescriptions, you would know my anger!

mindboggling
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Re: A sad tale with a good ending

Post by mindboggling » Sat Nov 16, 2019 10:24 am

I am retired and on Medicare. I have a part D drug plan that uses network pharmacies as well as "preferred" pharmacies. Right now most of my meds are cheap so the price difference is not significant to me. If I was on more expensive meds, however, that raises the stakes and I would be more diligent about only using the preferred pharmacies. One really has to read the policy carefully and navigate the website carefully!
In broken mathematics, We estimate our prize, --Emily Dickinson

sport
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Re: A sad tale with a good ending

Post by sport » Sat Nov 16, 2019 10:35 am

My Part D plan has 4 categories of pharmacies: Out of network, in network, in network preferred, and mail order. With any medical/prescription/dental insurance, one needs to understand the system and pay attention to the details.

J295
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Re: A sad tale with a good ending

Post by J295 » Sat Nov 16, 2019 10:42 am

Thank you for the information. It’s a challenging area for a consumer to navigate.

Nowizard
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Re: A sad tale with a good ending

Post by Nowizard » Sat Nov 16, 2019 10:45 am

He might check to see if mail order would save, too. Though things appear settled now, there are still other aspects of policies that could kick in if prescribed a new medication.

Tim

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unclescrooge
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Re: A sad tale with a good ending

Post by unclescrooge » Sat Nov 16, 2019 11:03 am

Thanks for sharing.

KlangFool
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Re: A sad tale with a good ending

Post by KlangFool » Sat Nov 16, 2019 11:16 am

OP,

A) Case 1:
Did he check with GoodRX too?

In my case, filling the prescription with the GoodRX (no insurance needed) instead of my health insurance would have saved me about $80 in one case.

B) Case 2:

It started with eye drops that cost $200 per month. The pharmacist suggests that I should look for an alternative. The eye drops that may cause irritation to some people is $10 per month for one drop per day. I say I won't mind doing 2 drops per day. In the end, the third option is $15 for 3 months. So, it went down from $600 for 3 months to $15 for 3 months.

Ask your pharmacist for alternatives and get your doctor to prescribe something else if it costs too much.


It is very simple.

It pays to shop around as soon as your prescription is more than $20.

KlangFool

Dead Man Walking
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by Dead Man Walking » Sat Nov 16, 2019 3:48 pm

The cheapest option with my Medicare part D prescription plan is a 90 day supply through the mail order option. I receive my insulin in styrofoam coolers via Fed Ex. My other meds arrive via US mail. Some people are not comfortable receiving meds through the mail and are willing to pay higher prices at preferred pharmacies.

DMW

donall
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by donall » Sat Nov 16, 2019 10:01 pm

Yes also learned about Preferred Pharmacies the hard way years ago when buying drugs for a relative. Previously only knew about in or out of network categories.

brennok
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by brennok » Sat Nov 16, 2019 10:12 pm

This isn’t all that uncommon unfortunately. We see it all the time even with medical visits. People opt for the tiered plan, but never bother to check what tier their doctor is. Then they are shocked when the copay isn’t $10.This is especially true for NPs and PAs since many if not most plans don’t rate these providers so they never qualify for the top tier.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by snackdog » Sat Nov 16, 2019 10:21 pm

I thought that was how preferred provider schemes work- pay more out of network and less or nothing in network.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by Dottie57 » Sat Nov 16, 2019 10:25 pm

OP,

Mom and I found out about preferred pharmacies with Part D several years ago. All f a sudden with the new year her prescriptions at Walgreens cost a lot more. She call insurance company and low and behold CVS was now preferred. At CVS ALL OF HER GENERICS WERE “free” - she pays a good amount for ins. The Walgreens and CVS. Are next to each other.

We could not find an info on mailed material to tell that CVS was preferred and therefore cheaper.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by HereToLearn » Sat Nov 16, 2019 10:29 pm

One drawback of paying cash and not running the expense through the insurance is the the amount paid will accumulate toward the plan's OOP max. By mid-November, most people have a fairly good idea where they stand on satisfying the plan's annual limits, so something to consider.

I have found that some prescriptions, mostly dermatology, have these discount programs in place that will reduce OOP cost from $700 to say $75. For reasons that I do not understand, that $75 copay is not appearing on my claim summary and therefore not accumulating toward my high deductible. Since I do not expect to hit my deductible this year, I am better off paying $75 than $700.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by drawpoker » Sat Nov 16, 2019 10:39 pm

HereToLearn wrote:
Sat Nov 16, 2019 10:29 pm
One drawback of paying cash and not running the expense through the insurance is the the amount paid will accumulate toward the plan's OOP max..........
Don't you have a typo here, left off the all-important word "not"


Not running through the insurance results in the amount paid Will Not accumulate (count) towards the Plan OOP.

HereToLearn
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by HereToLearn » Sat Nov 16, 2019 10:58 pm

drawpoker wrote:
Sat Nov 16, 2019 10:39 pm
HereToLearn wrote:
Sat Nov 16, 2019 10:29 pm
One drawback of paying cash and not running the expense through the insurance is the the amount paid will accumulate toward the plan's OOP max..........
Don't you have a typo here, left off the all-important word "not"


Not running through the insurance results in the amount paid Will Not accumulate (count) towards the Plan OOP.
YES!!! You are correct! Paying cash OOP means expense will not accumulate toward plan's OOP max or high deductible, if applicable.

Should I edit that or leave as is?

NewMoneyMustBeSmart
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by NewMoneyMustBeSmart » Sun Nov 17, 2019 9:40 am

cresive wrote:
Sat Nov 16, 2019 10:04 am
This is a true story of our [confusing -- mod oldcomputerguy] Medical System!!

At the risk of having another post removed, I think this needs to be said! This is not a post for medical advice, but to alert our community of how complex paying for medicines can be.
I empathize for your friend. However, I am disdainful of any notion or assumption that the system will take care of you optimally - be it government, insurance, etc..

I believe your anecdote reduces to two maxims:

1. Know your market when purchasing
2. Price shop

It's great to increase the awareness, though - thank you for doing that.

annebert
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by annebert » Sun Nov 17, 2019 10:17 am

By using GoodRx, I learned that the everyday cost for a drug I take was >$100 cheaper at Costco than from my plan's online pharmacy WITH insurance. GoodRX saved me another $5 or so. My deductible is $4500, so paying direct makes more sense.Costco's direct drug prices are really good, it's worth checking out.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by Farmboyslim83 » Sun Nov 17, 2019 1:48 pm

*Almost all Part D plans have a preferred pharmacy option, some have substantial differences in co-pay, preferred vs. non- preferred, do your homework, when choosing a plan, then when choosing a pharmacy.

*If paying cash, you’d be hard pressed to beat Walmart or Costco. As others have recommended, use GoodRx, Blink etc., to search for the best cash deal, especially for brand drugs.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by michaeljc70 » Sun Nov 17, 2019 10:45 pm

This is not entirely on topic (but not off topic either), but I went and got a flu shot the other day at Costco. I know they are $10-$20 cheaper at Costco than CVS/Walgreens/etc. I gave my insurance card, but had to pay out of pocket. No big deal, it was $20. It was preventative and I looked it up to see why it wasn't covered. It seems if I went to CVS/Walgreens it would have been covered. Lesson learned.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by sport » Mon Nov 18, 2019 9:37 am

michaeljc70 wrote:
Sun Nov 17, 2019 10:45 pm
This is not entirely on topic (but not off topic either), but I went and got a flu shot the other day at Costco. I know they are $10-$20 cheaper at Costco than CVS/Walgreens/etc. I gave my insurance card, but had to pay out of pocket. No big deal, it was $20. It was preventative and I looked it up to see why it wasn't covered. It seems if I went to CVS/Walgreens it would have been covered. Lesson learned.
In my experience, flu shots are covered by medical insurance, not prescription insurance. See if your medical insurance will reimburse you.

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Just sayin...
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by Just sayin... » Mon Nov 18, 2019 10:07 am

annebert wrote:
Sun Nov 17, 2019 10:17 am
By using GoodRx, I learned that the everyday cost for a drug I take was >$100 cheaper at Costco than from my plan's online pharmacy WITH insurance. GoodRX saved me another $5 or so. My deductible is $4500, so paying direct makes more sense.Costco's direct drug prices are really good, it's worth checking out.
100% agree - although with GoodRx I am within $2 of Costco’s price at my local Safeway pharmacy which is walking distance. Both cheaper (when factoring in gas and car expenses) and healthier than driving to Costco.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by dm200 » Mon Nov 18, 2019 10:36 am

A Medicare Advantage (MA) plan is being heavily advertised locally that has Walgreen's pharmacy as the "preferred" pharmacy - promoting its low cost prescriptions as a part of this MA plan.

Yes - "confusing" medical system indeed! It can pay to: 1. Read and understand the "fine print"; and 2. Discuss/chat with Pharmacists and Physicians about drug choices and prices. Note that when you see one of those drug company reps in your Physician's office, be 100% sure he/she is not pitching the low cost (but effective) drugs to the Physician!

My wife and I are fortunate that neither of us takes expensive drugs and it is very convenient and cost-effective to use our Kaiser Medicare plan. All but one of our prescriptions can be refilled (90 day supply) by mail. One of mine and one of my wife's is "No Charge" when refilled by mail!

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by Cooper62 » Mon Nov 18, 2019 1:37 pm

We always check how much we'd pay with insurance and without at various pharmacies and Good Rx. With insurance has always been most expensive. My daughter and I need epi-pens. Through our employer sponsored Aetna plan the cost is $230 each. Through Good Rx we got them for $100 less. We have to get new ones each year so $200/year adds up. My husband takes medication where a three month supply is $195 through Aetna insurance. CVS without insurance was the cheapest option at $43 for a three month supply. We had to educate my daughter when she went to college to check her app while still at the doctor. One visit he prescribed a $700/month medication that was not in the budget. If she checks right away she can tell him they need to find an alternative before leaving the office and prevents having to call back for other options.
Very frustrating for everyone.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by downshiftme » Mon Nov 18, 2019 2:03 pm

I don't have much advice how best to navigate this, but I can describe some of my similar issues, although with lower cost medicine. From month to month, the same prescription can change cost 3x or more. This was because an insurer changed their formulary and moved a drug from one reimbursement schedule to a different one. Same drug, same pharmacy, same prescription. The change was on a refill that was part of the original prescription.

Different pharmacy offered the same drug at a different price about midway between the old price and the new price, but to get that price I had to transfer the prescription from pharmacy to pharmacy, only to discover that the original pharmacy wouldn't do the transfer and suggested I needed to get a new prescription from the doctor office.

Doctor office wouldn't reissue the prescription without an office visit (paid).

Meanwhile the insurer introduced a new mail order "benefit" which required all long term prescriptions be sent only to their preferred mail order pharmacy. Long term prescriptions could be filled only three times at a local pharmacy and that was three times total, not per medication. The mail order pharmacy could not tell the price until after the prescription was sent to them and the order was filled. They only billed AFTER they shipped the medication. Tried this once when they assured me that they were preferred because they were almost certain to be the lowest cost. They weren't. They were slightly higher than the second pharmacy (which was no longer permitted on the insurance plan).

Turns out this was a pretty common medication and Walmart has a special list of drugs that can be purchased for a fixed amount. Paying cash and not using insurance at all was less expensive than either pharmacy with insurance or mailorder for one medication, about the same for a second drug and mail order was free for a third drug.

This is a lot of investigation and effort to keep track of the best cost and it changes from month to month. I usually only find that out after a refill is surprisingly costly, and then I have to decide whether to take a chance on pushing the prescription elsewhere to check the price. For my not especially expensive medications it is annoying. Had any of these been more expensive drugs I would have been forced to manage multiple prescriptions at multiple suppliers to be affordable.

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cresive
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Re: A sad tale with a good ending

Post by cresive » Mon Nov 18, 2019 4:40 pm

KlangFool wrote:
Sat Nov 16, 2019 11:16 am
OP,

A) Case 1:
Did he check with GoodRX too?

In my case, filling the prescription with the GoodRX (no insurance needed) instead of my health insurance would have saved me about $80 in one case.



Yes, GoodRx is how he found the pharmacy in the grocery store. Once he was there, thanks to the pharmacist insisting he double check his insurance, is when he discovered the "preferred" status.




B) Case 2:

It started with eye drops that cost $200 per month. The pharmacist suggests that I should look for an alternative. The eye drops that may cause irritation to some people is $10 per month for one drop per day. I say I won't mind doing 2 drops per day. In the end, the third option is $15 for 3 months. So, it went down from $600 for 3 months to $15 for 3 months.

Ask your pharmacist for alternatives and get your doctor to prescribe something else if it costs too much.


ALways do, but my friend is on a couple new medications that have no generics or substitutes--hence the exorbitant prices


It is very simple.

It pays to shop around as soon as your prescription is more than $20.

KlangFool

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cresive
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by cresive » Mon Nov 18, 2019 4:42 pm

snackdog wrote:
Sat Nov 16, 2019 10:21 pm
I thought that was how preferred provider schemes work- pay more out of network and less or nothing in network.
First of all, my secondary point was that there shouldn't be an "out of network" option. If a drug is added to a formulary, then it should be covered, regardless of which pharmacy you go to.

However, my original point was that this "network" was not clearly defined in the paperwork. Had he not stumbled upon it, he would have never known he was wasting money. This is NOT how the system should work.

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dm200
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by dm200 » Mon Nov 18, 2019 4:55 pm

cresive wrote:
Mon Nov 18, 2019 4:42 pm
snackdog wrote:
Sat Nov 16, 2019 10:21 pm
I thought that was how preferred provider schemes work- pay more out of network and less or nothing in network.
First of all, my secondary point was that there shouldn't be an "out of network" option. If a drug is added to a formulary, then it should be covered, regardless of which pharmacy you go to.
However, my original point was that this "network" was not clearly defined in the paperwork. Had he not stumbled upon it, he would have never known he was wasting money. This is NOT how the system should work.
With our Kaiser medicare plans, there are two or three "levels" of Pharmacies - and you pay a slightly different amount depending on the category of Pharmacy. My wife and I, though, just drive a little further and fill our in person prescriptions at a Kaiser pharmacy (lowest cost).

I do not know for sure, but I think it has become very common that there are preferred and non-preferred pharmacies - and the prices charged are different.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by rich126 » Mon Nov 18, 2019 4:56 pm

While it could be fine print, generally it is not fine print. I recently changed jobs this past summer and while glancing through the information I noted that some pharmacies (Walmart, Walgreens, etc.) are preferred and others (CVS) are not. Previously I had Blue Cross/Blue Shield through the government and my insurance was pretty solid. I heard coworkers complaining about my current insurance but so far my prescriptions (fortunately few) and even my shingle shots have had $0 copay.

And I'm not someone who has interest in reading fine print on everything so usually this info is not hidden, at least not in my experiences. You'd think a banker could have figured this out on his own.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by KlangFool » Mon Nov 18, 2019 4:58 pm

cresive wrote:
Mon Nov 18, 2019 4:42 pm
snackdog wrote:
Sat Nov 16, 2019 10:21 pm
I thought that was how preferred provider schemes work- pay more out of network and less or nothing in network.
First of all, my secondary point was that there shouldn't be an "out of network" option. If a drug is added to a formulary, then it should be covered, regardless of which pharmacy you go to.

However, my original point was that this "network" was not clearly defined in the paperwork. Had he not stumbled upon it, he would have never known he was wasting money. This is NOT how the system should work.
cresive,

My default expectation is the system does not work. I have no expectation that the system works in any rational fashion. So far, none of my experiences has proven me wrong.

Some of the more interesting examples are depending on how the medical procedures are coded, it may or may not be paid by the medical insurance. It is the exact same procedure.

KlangFool

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by NYGiantsFan » Mon Nov 18, 2019 5:23 pm

Our insurance allows price comparison online from pharmacy.
https://my.cigna.com/web/secure/my/esti ... lookuptool
From that, we found out that Walmart 90 days supply is cheaper than mail order!

downshiftme
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by downshiftme » Mon Nov 18, 2019 10:09 pm

It is very simple.

It pays to shop around as soon as your prescription is more than $20.

KlangFool
I'm not sure how this shopping around is possible, If I call a pharmacy they usually cannot give me a price unless they also have all of my insurance info and enroll me into their tracking system. Some pharmacies, such as the mail order pharmacy we are required to use, only give prices after the order is filled, never in advance. To get a price if I'm willing to switch pharmacies may also involve transferring a prescription or getting a doctor to write a new one for each new pharmacy I want to compare. And even when I've previously had a prescription filled at a pharmacy, the refills can change price dramatically when the insurance company pushes new schedules to the pharmacy but there is no notification to me until the cashier presents the bill.

In some cases I've been able to get cash prices or use GoodRx to compare cash prices, but once insurance gets involved simple shopping around seems impractical.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by AlphaLess » Mon Nov 18, 2019 10:24 pm

Thank you for the post.

As a family of fairly young people, we don't have that many prescription needs.

However, this is a good thing to know, as I expect that our health system will only become more f-ed up.
"A Republic, if you can keep it". Benjamin Franklin. 1787. | Party affiliation: Vanguard. Religion: low-cost investing.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by KlangFool » Mon Nov 18, 2019 10:32 pm

downshiftme wrote:
Mon Nov 18, 2019 10:09 pm
It is very simple.

It pays to shop around as soon as your prescription is more than $20.

KlangFool
I'm not sure how this shopping around is possible, If I call a pharmacy they usually cannot give me a price unless they also have all of my insurance info and enroll me into their tracking system. Some pharmacies, such as the mail order pharmacy we are required to use, only give prices after the order is filled, never in advance. To get a price if I'm willing to switch pharmacies may also involve transferring a prescription or getting a doctor to write a new one for each new pharmacy I want to compare. And even when I've previously had a prescription filled at a pharmacy, the refills can change price dramatically when the insurance company pushes new schedules to the pharmacy but there is no notification to me until the cashier presents the bill.

In some cases I've been able to get cash prices or use GoodRx to compare cash prices, but once insurance gets involved simple shopping around seems impractical.
downshiftme,

<<I'm not sure how this shopping around is possible, >>

It is very simple as in everything else in life.

You have a choice. If you do not know how to do something, you could assume that it is impossible. Or, you could ask around and learn how to do it.

My question to you is very simple.

Did you start a topic and ask how to do this shopping before? If not, why not?

<< only give prices after the order is filled, never in advance. >>

And, you could refuse to accept the prescription order if the price is too high and/or go back later. They will hold the order for 7 days for me and automatically cancel the order if I do not pick it up.

And, why do I know this? I ask the pharmacist whether I can refuse to take the prescription order. I do not assume that it is not possible.

KlangFool

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by Elixir » Tue Nov 19, 2019 6:33 am

Pharmacist here.

With regards to comparing prices at various drug stores when using insurance, the simplest way for all parties involved is to call the number on your insurance card and ask. “What’s the price if I get this drug and quantity at drug store A vs B?” This will save you the hassle of getting scripts transferred or from having to get a new one. And it will also save the pharmacies time transferring (time consuming especially in snowbird states).

When talking about discount cards like goodrx etc, it becomes a little tricky in some cases. There is no way in my system that I am able to run a “test claim” to check the price through a discount card (meaning we would need the script and for you to have an account with us). In most cases the price you are quoted if using an app like goodrx is correct or close, but sometimes it is not. This is due to cost differences between identical generics from different manufacturers. I always tell my patients when using discount cards that this can be the case and that it can change at any time.

What Klangfool said is correct about having no obligation to pick something up. Obviously we would prefer that you did, but in most cases you will receive a couple reminder calls and then we will un-fill the prescription after 10-14 days. At which point you are free to leave it like that or have it transferred elsewhere.

downshiftme
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by downshiftme » Tue Nov 19, 2019 5:03 pm

the simplest way for all parties involved is to call the number on your insurance card and ask. “What’s the price if I get this drug and quantity at drug store A vs B?”
I understand that ASKING is the first step in shopping when prices are all over the place. But I have done exactly that and have NOT found the helpful people you imply will answer my question. They always said that they cannot know until they see the specific prescription or order. I have tried giving the exact details of the prescription and that wasn't good enough. They required an actual prescription in the system to be requested to be filled at a specific pharmacy.

And yes, I do understand that I can refuse to pick up the prescription if I don't like the price and try again elsewhere. This doesn't actually work with the mail-order option my insurance requires since the price is not available until after the package is shipped, but I suppose it might be possible to refuse delivery - which sounds like it's own problems since the payment is already made (as required) by a card on file (as required).

With extraordinary effort some small amount of price checking is almost sort-of possible, but it is not very transparent and it requires an inordinate amount of effort that I would only be willing to expend for very high priced medications. Maybe my insurance is especially good at hiding prices, but I've had similar issues with three different insurers.

Lastly, let me add that prescription refills are generally controlled so that there is a limited time before I need to get the refill or new prescription filled. Taking the time to order, get filled, get the price, refuse the high price, shop around to place a second order (maybe asking for a second prescription), repeat repeat repeat all while under time pressure as pills are running out would also add considerably to the stress of trying to deal with these pricing anomalies.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by sport » Tue Nov 19, 2019 5:33 pm

I have found when calling the Rx insurance that they sometimes do not know what they are talking about. We had one year when the preferred pharmacies changed, and a store that they told us would be preferred actually turned out to be not preferred. So, we moved our prescriptions there, and then had to move them a second time. When I asked which stores in my area would be preferred, they specified a Walmart. What they did not offer was the Walmart around the corner which was also preferred. Depending on the route I chose, I would actually drive past the Walmart they did not suggest to get to the one they did. BTW, this paragon of efficiency is Express Scripts. :annoyed

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by KlangFool » Tue Nov 19, 2019 8:25 pm

downshiftme wrote:
Tue Nov 19, 2019 5:03 pm

And yes, I do understand that I can refuse to pick up the prescription if I don't like the price and try again elsewhere. This doesn't actually work with the mail-order option my insurance requires since the price is not available until after the package is shipped, but I suppose it might be possible to refuse delivery - which sounds like it's own problems since the payment is already made (as required) by a card on file (as required).
downshiftme,

A) Is that really true? Did you call and ask what is the procedure to refuse an order? Given the consumer protection law in this country, they have to offer you a method to refuse the order if they cannot show you the price of your order.

B) As per my insurance, I could get the same price and option as per my mail-order option from my preferred provider.

<<which sounds like it's own problems since the payment is already made (as required) by a card on file (as required).>>

C) If it is a credit card, you can cancel the order by rejecting the payment. It is never a problem with a credit card versus an online order.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by KlangFool » Tue Nov 19, 2019 8:29 pm

downshiftme wrote:
Tue Nov 19, 2019 5:03 pm
the simplest way for all parties involved is to call the number on your insurance card and ask. “What’s the price if I get this drug and quantity at drug store A vs B?”
I understand that ASKING is the first step in shopping when prices are all over the place. But I have done exactly that and have NOT found the helpful people you imply will answer my question. They always said that they cannot know until they see the specific prescription or order. I have tried giving the exact details of the prescription and that wasn't good enough. They required an actual prescription in the system to be requested to be filled at a specific pharmacy.
downshiftme,

But, did you post a topic on this forum and ask that specific question?

How do I shop for a prescription if I have XYZ insurance?

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by celia » Tue Nov 19, 2019 9:12 pm

sport wrote:
Tue Nov 19, 2019 5:33 pm
What they did not offer was the Walmart around the corner which was also preferred. Depending on the route I chose, I would actually drive past the Walmart they did not suggest to get to the one they did. BTW, this paragon of efficiency is Express Scripts. :annoyed
That's likely not their fault. Since we live a block away from the city limits, I find that using my city vs the neighboring one (or my zip vs the neighboring one) gives different search results. I easily figured that out when my zip would show the closest <whatever> was located AT THE CENTER OF MY ZIP, which is not near me. So it pays to know where your city and zip code boundaries are.

I also found that our current pharmacy gave me a high price for a drug that I had been taking for a long time. When I asked them to run it through my insurance plan, they said they had. So I asked what I had previously paid and why it was now so much more expensive. They looked at my records and were confused, until they figured out I had a new "insurance plan". I assured them I did not. It turned out to be a "discount plan" that my secondary insurance offered for free. While talking to my secondary plan to have it be removed, they added the discount plan on the phone call as a third party, and happened to ask how much my discount was for that med. The answer was: zero. Of course, I had to get off that UN-discounted plan so that my real insurance plan could pay their part.

As I often tell others, in regards to any benefit they have (not just drug plans), it is your responsibility to understand your plan and get billed accordingly. If you don't care to understand your benefits, well, nobody will understand them for you. This applies to extended warranties, credit card benefits, any insurances (as examples).

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by drawpoker » Tue Nov 19, 2019 9:55 pm

celia wrote:
Tue Nov 19, 2019 9:12 pm
.......in regards to any benefit they have (not just drug plans), it is your responsibility to understand your plan and get billed accordingly. If you don't care to understand your benefits, well, nobody will understand them for you. This applies to extended warranties, credit card benefits, any insurances (as examples).
In principle would agree 100% with that advice.

However, as relates to this thread, I tend to be a bit more charitable here. As happens so often, apples & oranges.

OP wrote about someone not yet on a Medicare Part D plan. Rather a 53-yr old, suddenly dumped from his long-term job, ending up relying on the COBRA benefits, trying to best navigate the financial challenges.

Under these circumstances, Who is going to remember the fine print in language of their employer-provided health insurance? Esp. with regard to the prescription drug coverage? While going thru the nightmare of sudden unemployment?

Add to that - it was probably years ago, at the time the employee's insurance benefits first became effective, he had any reason to sit down and read it through.

This thread is representative of how senior citizens, as ironic as it is, who are on Part D plans, do have a foot up on these all-important details. As opposed to the under-65 group. Medicare-age folks get an annual reminder of what their Rx insurance covers, and, a heads-up on any changes coming.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by sport » Tue Nov 19, 2019 10:30 pm

celia wrote:
Tue Nov 19, 2019 9:12 pm
sport wrote:
Tue Nov 19, 2019 5:33 pm
What they did not offer was the Walmart around the corner which was also preferred. Depending on the route I chose, I would actually drive past the Walmart they did not suggest to get to the one they did. BTW, this paragon of efficiency is Express Scripts. :annoyed
That's likely not their fault. Since we live a block away from the city limits, I find that using my city vs the neighboring one (or my zip vs the neighboring one) gives different search results. I easily figured that out when my zip would show the closest <whatever> was located AT THE CENTER OF MY ZIP, which is not near me. So it pays to know where your city and zip code boundaries are.

I also found that our current pharmacy gave me a high price for a drug that I had been taking for a long time. When I asked them to run it through my insurance plan, they said they had. So I asked what I had previously paid and why it was now so much more expensive. They looked at my records and were confused, until they figured out I had a new "insurance plan". I assured them I did not. It turned out to be a "discount plan" that my secondary insurance offered for free. While talking to my secondary plan to have it be removed, they added the discount plan on the phone call as a third party, and happened to ask how much my discount was for that med. The answer was: zero. Of course, I had to get off that UN-discounted plan so that my real insurance plan could pay their part.

As I often tell others, in regards to any benefit they have (not just drug plans), it is your responsibility to understand your plan and get billed accordingly. If you don't care to understand your benefits, well, nobody will understand them for you. This applies to extended warranties, credit card benefits, any insurances (as examples).
I disagree. I did not ask for preferred stores in my zip code, I asked for preferred stores close to my home address. If they are going to provide customer service, they should know where to look. You also did not quote my entire post. They did not even know which stores were preferred in my plan and which were not.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by White Coat Investor » Wed Nov 20, 2019 12:18 am

The biggest problem with all these complications is that the doctors don't know the prices of the prescriptions they write either, otherwise they often wouldn't even write them and you wouldn't have to shop around. It's the blind leading the blind when it comes to prices.
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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by HereToLearn » Wed Nov 20, 2019 12:52 am

White Coat Investor wrote:
Wed Nov 20, 2019 12:18 am
The biggest problem with all these complications is that the doctors don't know the prices of the prescriptions they write either, otherwise they often wouldn't even write them and you wouldn't have to shop around. It's the blind leading the blind when it comes to prices.
This is completely true. I report back when I learn prices, just so that the Dr will know.

I have a dermatology RX (so completely nothing life-threatening). Brand was nearly $800 per fill, and when I lamented the price, the Dr offered that a generic was now available. Generic cost was $400. Fortunately the pharmacist tech knew some coupon program that brought the brand cost down to $75, but the generic was still $400.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by fru-gal » Wed Nov 20, 2019 5:50 am

dm200 wrote:
Mon Nov 18, 2019 4:55 pm
cresive wrote:
Mon Nov 18, 2019 4:42 pm
snackdog wrote:
Sat Nov 16, 2019 10:21 pm
I thought that was how preferred provider schemes work- pay more out of network and less or nothing in network.
First of all, my secondary point was that there shouldn't be an "out of network" option. If a drug is added to a formulary, then it should be covered, regardless of which pharmacy you go to.
However, my original point was that this "network" was not clearly defined in the paperwork. Had he not stumbled upon it, he would have never known he was wasting money. This is NOT how the system should work.
With our Kaiser medicare plans, there are two or three "levels" of Pharmacies - and you pay a slightly different amount depending on the category of Pharmacy. My wife and I, though, just drive a little further and fill our in person prescriptions at a Kaiser pharmacy (lowest cost).

I do not know for sure, but I think it has become very common that there are preferred and non-preferred pharmacies - and the prices charged are different.
There are three levels of pharmacy with my AARP Plan D. This is clearly stated on the website in the section where one looks for local pharmacies. I assume these levels exist because the insurer and the pharmacy chain have worked out some pricing arrangement, as it is clearly worth something to a chain to be preferred.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by celia » Wed Nov 20, 2019 6:04 am

drawpoker wrote:
Tue Nov 19, 2019 9:55 pm
celia wrote:
Tue Nov 19, 2019 9:12 pm
.......in regards to any benefit they have (not just drug plans), it is your responsibility to understand your plan and get billed accordingly. If you don't care to understand your benefits, well, nobody will understand them for you. This applies to extended warranties, credit card benefits, any insurances (as examples).
In principle would agree 100% with that advice.

However, as relates to this thread, I tend to be a bit more charitable here. As happens so often, apples & oranges.
My intent in that post was to show other things to be aware of and other examples of "fine print" that people often don't read/understand.
OP wrote about someone not yet on a Medicare Part D plan. Rather a 53-yr old, suddenly dumped from his long-term job, ending up relying on the COBRA benefits, trying to best navigate the financial challenges.

Under these circumstances, Who is going to remember the fine print in language of their employer-provided health insurance? Esp. with regard to the prescription drug coverage? While going thru the nightmare of sudden unemployment?
As I understood the original post, the friend's coverage was the same as when working, so it had nothing to do with being unemployed. He was just not aware that the costs could differ depending on where you went.
This thread is representative of how senior citizens, as ironic as it is, who are on Part D plans, do have a foot up on these all-important details.
Oh yes, seniors are so lucky <sarcasm here> because they get to spend their free time figuring out all the permutations of how to get their meds for the least cost. Consider if you have multiple meds and they are all in different "tiers" (price "groupings" defined by each drug plan). Then you need to consider these variables:
* which drug plan you want for the year
* which pharmacy to use
* the order in which you pick up the meds
* what cost phase you are currently in (deductible-not-yet-met, initial, donut hole, catastopic) --because the same Rx will have a different cost depending on the phase you are in for that year
* what price the manufacturer is currently selling it for (which can change multiple times during the year)

Unless you only take a few meds on a Medicare drug plan and they are inexpensive, it often feels like the pricing is done by a random number generator since the price keeps changing, even within the same year. For the first two years, I thought I understood the pricing scheme quite well, but was continually frustrated by the actual price being different than I expected and what the Medicare cost estimator tool generated. So we now just go with the flow and accept that sometimes we are paying more than expected and sometimes less.
Last edited by celia on Wed Nov 20, 2019 6:46 am, edited 2 times in total.

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Re: A sad tale with a good ending ["Preferred" pharmacies vs "non-preferred"]

Post by Mr. Rumples » Wed Nov 20, 2019 6:35 am

After reading this post, I called Express Scripts through which I get my medications last night. The agent said there were no preferred pharmacies in my zip code. I then gave her the zip codes of two locations which have large populations, again she said there were no preferred pharmacies. I then asked if she could do a map view and she said no, so I said OK and hung up. I called back and got another agent who said the same thing, but then said that can't be right. He was then mumbling to himself and I asked if he could do a map view, he said that is what he was doing and was finding it odd it was not showing any preferred pharmacies anywhere in my state. He asked if I would hold and I was on hold for over 10 minutes. He then said there is a different system which shows some of them but it stops in the middle of the list. I asked what he meant by that and he said he could see the name and address but not the information on one so he knew it wasn't working right. I'm not sure of the impact this has on customers, but its disturbing that their agents are giving out incomplete or wrong information. But at least I found out that there are several preferred pharmacies in my area.

Update: I called again today and was told there are no preferred pharmacies in my area! The agent sounded puzzled but did not explore it further so I have turned this over to my benefits ombudsman.

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