Call medical group about pharmacy network?

[michaeljc70]

A large chain grocery store pharmacy filled some prescriptions for me using a discount program. Some they said were cheaper with my insurance so they used that. This pharmacy does not appear in the provider directory of network pharmacies on the BCBS website or the pharmacy benefits manager website so I thought they were out of network. I emailed BCBS because for pharmacies that do show as in network, you can put in your prescriptions and see prices which is very helpful.

I contacted BCBS and they told me to contact my HMO group. They gave me a number for a hospital. I called, and as I expected, they had no idea what I was talking about. Certainly this doctor/hospital group has nothing to do with pharmacies that aren't in their facilities. Am I missing something? Is BCBS just giving me bad information (again)? I've never heard of a medical group having anything to do with outpatient medication claims.

[Silk McCue]

You were given bad advice. Of course the medical group knows nothing about your pharmacy network.

Cheers

[OnTrack2020]

What exactly are you trying to find out? It seems your BCBS knows what pharmacies are in-network. And it seems this grocery store pharmacy gave you a discount. I'm thinking the grocery store chain gave you a discount as if you were a cash-paying customer. Is there something more you want to do with that information?

The medical group will know nothing about your pharmacy network.

[BBBob]

It sounds like you are talking about market pharmacies that are part of either GoodRX or Singlecare networks. If that is the case, their prices can indeed be cheaper than your insurance company's formulary price. I don't understand the intricacies of pharma pricing, but if that is the case, the market pharmacy may indeed have done you a favor.

[Chant]

Pricing of all facets of healthcare is extremely opaque, so I understand your frustration. With regards to pharmaceuticals, my understanding of various pricing follows:

- Insurance pricing as negotiated through the PBM for the given plan (pay attention to in-network vs. out-of-network as pricing will differ)
- pricing obtained through generic discount programs offered via the pharmacy itself
- discount programs offered thru apps which will offer a one-time price followed by a ‘regular’ price for future refills

Communication with the pharmacy is key as they need to understand how they are processing the prescription. Most chain pharmacies will keep your regular insurance info in the computer system and use this as the processing default. You need to tell the pharmacy ahead of time if you’d like to use their discount program (provided they offer your prescribed medication at a discount - you need to find out…usually these are generics). If using an app (GoodRx, SilverCare, etc) let them know that so they process the costs in that direction before pick-up - usually generics as well and, they lure you in with a big discount for the first prescription.

Caveat: if you have a separate pharmacy benefit (not combined with medical), you may have a pharmacy deductible just like you have a medical deductible. So, you need to understand that. Regardless, the cost of meds purchased through discount programs, outside of your insurance, will not be applied to insurance deductibles. The benefit is just saving some $ up front.

I hope this might help.

[michaeljc70]

What exactly are you trying to find out? It seems your BCBS knows what pharmacies are in-network. And it seems this grocery store pharmacy gave you a discount. I'm thinking the grocery store chain gave you a discount as if you were a cash-paying customer. Is there something more you want to do with that information?

The medical group will know nothing about your pharmacy network.

It is very simple. This pharmacy chain (Kroger) is clearly not out of network since they processed claims through my insurance. They are not in the directory as in network. They should be. That would enable me to compare prices across in network pharmacies without going there or calling them for every prescription.

Apparently BCBS doesn't know as they told me to contact the HMO group!

Maybe it is just me (doubt it)...but it seems customer service widely (not just healthcare) has the goal of deflecting and getting rid of you as quick as possible.

[michaeljc70]

It sounds like you are talking about market pharmacies that are part of either GoodRX or Singlecare networks. If that is the case, their prices can indeed be cheaper than your insurance company's formulary price. I don't understand the intricacies of pharma pricing, but if that is the case, the market pharmacy may indeed have done you a favor.

That isn't the issue. The issue is my insurance company is showing an in network pharmacy as out of network, Therefore, they aren't showing the prescription prices online through that pharmacy. The discount program is a red herring.

[michaeljc70]

You were given bad advice. Of course the medical group knows nothing about your pharmacy network.

Cheers

Agreed.

Sadly, through the ACA, I had plans many years through unknown (I'm being kind...fly by night is a better term), companies. I thought going back to BCBS would be a big change. Sadly, they are as bad or worse than the unknown carriers. Maybe it is just a race to the bottom. Maybe because I have an HMO the service is worse.

[michaeljc70]

I should add that my insurance doesn't cover any prescriptions until I meet my deductible ($7k) that is why I shop around. The price differences between using various discount programs, the insurance discount and varying pharmacies are huge.

[Jack FFR1846]

It's a vast, complicated web of CSRs who have no idea, systems that are not updated and providers who "think" they're in network but aren't. Good luck figuring it out. A possible method would be to put in an order for a prescription and find out what your cost is through your insurance. Then ask about things like Good RX or the like. Look for the specific medication and especially if it's a TV med (you see commercials on TV), the pharma company may have a discount program.

Not on the pharma side, but when looking for a new PCP, I first used my insurance company's site as recommended. Of the first 4 doctors recommended, 2 were dead and 2 were no longer in the area. I called my insurance company and they gave me the same 4 doctors. I informed them that none of them were available anymore. They seemed unconvinced until I let them know that 2 of them were dead. I suppose a doctor can be dead and still in network.

I'm about finished with my Medicare prep. (I retire in 4 weeks). I worked with an agent on a lot of the drug plan and it involves a medicare drug plan plus a program that groups meds for a common ailment (diabetes in my case) to get the insulin and then discount TV drugs (eliquis and jardiance) for a single, lower price. It would be $375 a month inside the drug plan but $59 with this program. In addition, the agent had me check Canadian mail order pharmacies (yes, it's legal) and they were indeed far cheaper than the medicare drug plan. And the pharmacy used matters. A med can cost $165 at one pharmacy and $50 at another. Why? Who knows?

As answered by others, a medical group won't have a clue about who else is in network.

[Kenkat]

I don’t have the issue you have, but I frequently ask Kroger to re-run prescriptions using either the Kroger Savings Club prescription service or my insurance and they can do it right on the spot in just a few seconds. I have a spreadsheet with prices and which is best. Kroger seems to “remember” which is best as long as there are refills remaining but when a new script is called in, even for an existing drug, it “forgets” and frequently runs the more expensive option until I tell them to try both.

I can look up drug prices on the CVS/Caremark website but I don’t really bother as it is easier to just handle at the pharmacy.

[michaeljc70]

I don’t have the issue you have, but I frequently ask Kroger to re-run prescriptions using either the Kroger Savings Club prescription service or my insurance and they can do it right on the spot in just a few seconds. I have a spreadsheet with prices and which is best. Kroger seems to “remember” which is best as long as there are refills remaining but when a new script is called in, even for an existing drug, it “forgets” and frequently runs the more expensive option until I tell them to try both.

I can look up drug prices on the CVS/Caremark website but I don’t really bother as it is easier to just handle at the pharmacy.

I do exactly that (I have the Kroger Savings club). The issue is that the prescription could be cheaper at Walgreens or CVS and I can't get the Kroger insurance price online because they aren't in the directory/tool. I have another thread on here detailing how a drug that I paid $4.85 for in March went to $82 in April at the same pharmacy with the same insurance. I was told the insurance prices can change quarterly.

How do you know if Kroger has the best price compared to other pharmacies? If you have a simple $$ co-pay I understand it would be the same anywhere. But I have to meet my deductible before anything is covered and find the prices vary widely. Of course, to make it more difficult, it is often the case where drug A is cheaper at pharmacy A and drug B is cheaper at pharmacy B. I'm not going to run around for $3 but for $50 I will.

[torso2500]

sounds like Kroger pharmacy can look up your insurance price if you request. Unfortunate that you can't just see it online yourself; sometimes the network look up tool is out of date.

[pizzy]

I don’t have the issue you have, but I frequently ask Kroger to re-run prescriptions using either the Kroger Savings Club prescription service or my insurance and they can do it right on the spot in just a few seconds. I have a spreadsheet with prices and which is best. Kroger seems to “remember” which is best as long as there are refills remaining but when a new script is called in, even for an existing drug, it “forgets” and frequently runs the more expensive option until I tell them to try both.

I can look up drug prices on the CVS/Caremark website but I don’t really bother as it is easier to just handle at the pharmacy.

I do exactly that (I have the Kroger Savings club). The issue is that the prescription could be cheaper at Walgreens or CVS and I can't get the Kroger insurance price online because they aren't in the directory/tool. I have another thread on here detailing how a drug that I paid $4.85 for in March went to $82 in April at the same pharmacy with the same insurance. I was told the insurance prices can change quarterly.

How do you know if Kroger has the best price compared to other pharmacies? If you have a simple $$ co-pay I understand it would be the same anywhere. But I have to meet my deductible before anything is covered and find the prices vary widely. Of course, to make it more difficult, it is often the case where drug A is cheaper at pharmacy A and drug B is cheaper at pharmacy B. I'm not going to run around for $3 but for $50 I will.

Since the Kroger price isn’t online, if you want to pursue this comparison shopping you’ll have to put in the leg work of calling Kroger each time and getting their price and then compare to what you can see online.

Relying on these frontline CSR’s to help is a fool’s errand.

[michaeljc70]

I don’t have the issue you have, but I frequently ask Kroger to re-run prescriptions using either the Kroger Savings Club prescription service or my insurance and they can do it right on the spot in just a few seconds. I have a spreadsheet with prices and which is best. Kroger seems to “remember” which is best as long as there are refills remaining but when a new script is called in, even for an existing drug, it “forgets” and frequently runs the more expensive option until I tell them to try both.

I can look up drug prices on the CVS/Caremark website but I don’t really bother as it is easier to just handle at the pharmacy.

I do exactly that (I have the Kroger Savings club). The issue is that the prescription could be cheaper at Walgreens or CVS and I can't get the Kroger insurance price online because they aren't in the directory/tool. I have another thread on here detailing how a drug that I paid $4.85 for in March went to $82 in April at the same pharmacy with the same insurance. I was told the insurance prices can change quarterly.

How do you know if Kroger has the best price compared to other pharmacies? If you have a simple $$ co-pay I understand it would be the same anywhere. But I have to meet my deductible before anything is covered and find the prices vary widely. Of course, to make it more difficult, it is often the case where drug A is cheaper at pharmacy A and drug B is cheaper at pharmacy B. I'm not going to run around for $3 but for $50 I will.

Since the Kroger price isn’t online, if you want to pursue this comparison shopping you’ll have to put in the leg work of calling Kroger each time and getting their price and then compare to what you can see online.

Relying on these frontline CSR’s to help is a fool’s errand.

Yep. I think my strategy going forward is to have my doctor send them to Kroger, check the status online (where I can see the price after they are filled) and then compare with other pharmacies/discounts and transfer the prescription if it is worth it.

[Kenkat]

I don’t have the issue you have, but I frequently ask Kroger to re-run prescriptions using either the Kroger Savings Club prescription service or my insurance and they can do it right on the spot in just a few seconds. I have a spreadsheet with prices and which is best. Kroger seems to “remember” which is best as long as there are refills remaining but when a new script is called in, even for an existing drug, it “forgets” and frequently runs the more expensive option until I tell them to try both.

I can look up drug prices on the CVS/Caremark website but I don’t really bother as it is easier to just handle at the pharmacy.

I do exactly that (I have the Kroger Savings club). The issue is that the prescription could be cheaper at Walgreens or CVS and I can't get the Kroger insurance price online because they aren't in the directory/tool. I have another thread on here detailing how a drug that I paid $4.85 for in March went to $82 in April at the same pharmacy with the same insurance. I was told the insurance prices can change quarterly.

How do you know if Kroger has the best price compared to other pharmacies? If you have a simple $$ co-pay I understand it would be the same anywhere. But I have to meet my deductible before anything is covered and find the prices vary widely. Of course, to make it more difficult, it is often the case where drug A is cheaper at pharmacy A and drug B is cheaper at pharmacy B. I'm not going to run around for $3 but for $50 I will.

I have one expensive, brand name prescription that has a $100 copay for a 90 day supply (retail is around $1600); all the others are under $20, so that issue hasn’t come up. I do see your dilemma however. Could you use the insurance web site to check other pharmacies in conjunction with something like GoodRx to see prices across pharmacies different than Kroger? That way you could get an insurance price and an alternate price using GoodRx. The Kroger Savings Club is typically better than GoodRx (it’s kind of equivalent to GoodRx Gold), but regular GoodRx can be cheaper than insurance as well.

I’d agree that I don’t bother for a few bucks, but $80 would make me shop around. It’s definitely what I would term “a racket”, along with the rest of the healthcare system.

[pizzy]

I don’t have the issue you have, but I frequently ask Kroger to re-run prescriptions using either the Kroger Savings Club prescription service or my insurance and they can do it right on the spot in just a few seconds. I have a spreadsheet with prices and which is best. Kroger seems to “remember” which is best as long as there are refills remaining but when a new script is called in, even for an existing drug, it “forgets” and frequently runs the more expensive option until I tell them to try both.

I can look up drug prices on the CVS/Caremark website but I don’t really bother as it is easier to just handle at the pharmacy.

I do exactly that (I have the Kroger Savings club). The issue is that the prescription could be cheaper at Walgreens or CVS and I can't get the Kroger insurance price online because they aren't in the directory/tool. I have another thread on here detailing how a drug that I paid $4.85 for in March went to $82 in April at the same pharmacy with the same insurance. I was told the insurance prices can change quarterly.

How do you know if Kroger has the best price compared to other pharmacies? If you have a simple $$ co-pay I understand it would be the same anywhere. But I have to meet my deductible before anything is covered and find the prices vary widely. Of course, to make it more difficult, it is often the case where drug A is cheaper at pharmacy A and drug B is cheaper at pharmacy B. I'm not going to run around for $3 but for $50 I will.

Since the Kroger price isn’t online, if you want to pursue this comparison shopping you’ll have to put in the leg work of calling Kroger each time and getting their price and then compare to what you can see online.

Relying on these frontline CSR’s to help is a fool’s errand.

Yep. I think my strategy going forward is to have my doctor send them to Kroger, check the status online (where I can see the price after they are filled) and then compare with other pharmacies/discounts and transfer the prescription if it is worth it.

Sounds reasonable. And you can weigh the price/hassle each time and have the Rx waiting if you choose to go with Kroger. If you find another pharmacy consistently beating Kroger, you can have the doc go with that pharmacy as the default going forward.

[Kenkat]

I don’t have the issue you have, but I frequently ask Kroger to re-run prescriptions using either the Kroger Savings Club prescription service or my insurance and they can do it right on the spot in just a few seconds. I have a spreadsheet with prices and which is best. Kroger seems to “remember” which is best as long as there are refills remaining but when a new script is called in, even for an existing drug, it “forgets” and frequently runs the more expensive option until I tell them to try both.

I can look up drug prices on the CVS/Caremark website but I don’t really bother as it is easier to just handle at the pharmacy.

I do exactly that (I have the Kroger Savings club). The issue is that the prescription could be cheaper at Walgreens or CVS and I can't get the Kroger insurance price online because they aren't in the directory/tool. I have another thread on here detailing how a drug that I paid $4.85 for in March went to $82 in April at the same pharmacy with the same insurance. I was told the insurance prices can change quarterly.

How do you know if Kroger has the best price compared to other pharmacies? If you have a simple $$ co-pay I understand it would be the same anywhere. But I have to meet my deductible before anything is covered and find the prices vary widely. Of course, to make it more difficult, it is often the case where drug A is cheaper at pharmacy A and drug B is cheaper at pharmacy B. I'm not going to run around for $3 but for $50 I will.

Since the Kroger price isn’t online, if you want to pursue this comparison shopping you’ll have to put in the leg work of calling Kroger each time and getting their price and then compare to what you can see online.

Relying on these frontline CSR’s to help is a fool’s errand.

Yep. I think my strategy going forward is to have my doctor send them to Kroger, check the status online (where I can see the price after they are filled) and then compare with other pharmacies/discounts and transfer the prescription if it is worth it.

You can check the Kroger Savings Club price online - https://www.krogersc.com/

[michaeljc70]

I don’t have the issue you have, but I frequently ask Kroger to re-run prescriptions using either the Kroger Savings Club prescription service or my insurance and they can do it right on the spot in just a few seconds. I have a spreadsheet with prices and which is best. Kroger seems to “remember” which is best as long as there are refills remaining but when a new script is called in, even for an existing drug, it “forgets” and frequently runs the more expensive option until I tell them to try both.

I can look up drug prices on the CVS/Caremark website but I don’t really bother as it is easier to just handle at the pharmacy.

I do exactly that (I have the Kroger Savings club). The issue is that the prescription could be cheaper at Walgreens or CVS and I can't get the Kroger insurance price online because they aren't in the directory/tool. I have another thread on here detailing how a drug that I paid $4.85 for in March went to $82 in April at the same pharmacy with the same insurance. I was told the insurance prices can change quarterly.

How do you know if Kroger has the best price compared to other pharmacies? If you have a simple $$ co-pay I understand it would be the same anywhere. But I have to meet my deductible before anything is covered and find the prices vary widely. Of course, to make it more difficult, it is often the case where drug A is cheaper at pharmacy A and drug B is cheaper at pharmacy B. I'm not going to run around for $3 but for $50 I will.

I have one expensive, brand name prescription that has a $100 copay for a 90 day supply (retail is around $1600); all the others are under $20, so that issue hasn’t come up. I do see your dilemma however. Could you use the insurance web site to check other pharmacies in conjunction with something like GoodRx to see prices across pharmacies different than Kroger? That way you could get an insurance price and an alternate price using GoodRx. The Kroger Savings Club is typically better than GoodRx (it’s kind of equivalent to GoodRx Gold), but regular GoodRx can be cheaper than insurance as well.

I’d agree that I don’t bother for a few bucks, but $80 would make me shop around. It’s definitely what I would term “a racket”, along with the rest of the healthcare system.

Yep. The Kroger RX Savings Club actually says "powered by GoodRx" and since you are paying an annual fee I would expect it to be cheaper than the regular GoodRx. GoodRx, in my experience, seems to give the cheapest price per drug the first time. I sometimes use incognito browser mode to see if I get a different price. Last week I had 5 prescriptions filled and 3 were cheaper with the Kroger savings plan and 2 were cheaper with my insurance discount.

[quantAndHold]

My wife has one prescription that’s cheaper going through GoodRX at Costco than using her insurance. So it pays to shop around.

I have a friend with a very expensive prescription ($6k/month). Every year at open enrollment, she calls all the plans and finds the one that covers it.