Health Insurance Craziness

[schildi]

So ... we are on a high deductible plan, and I just got a prescription for a cream against some warts on my left hand.

Anyways, as the pharmacy, we are using Costco. So I just called them, and the prescription is ready, but:
If I go through the insurance, my copay is $188. If I just buy it from Costco directly, bypassing the insurance, then it's $76.   Wondering why the insurance would make it more expensive.

That's crazy in itself IMO, but here is another funny thing about it: I will most likely still go through the insurance and pay $188. Reason is that in this case, it counts towards our deductible, and I am very sure that this year we'll reach the $4k limit, after which the insurance pays 90%, and we pay only 10%.
So by my calculation, we'll reach the limit earlier, and since we'll reach it anyways (most likley), getting the cream for $188 with the insurance involved will only really cost us $18.80.

Does that make sense? I think the system is weird.

[mollyanna58]

Yes, insurance reimbursements are weird, one of the reasons I now support Medicare for all.  However, are you sure prescriptions count towards your deductible? They don't on my insurance.  

[CCL]

They don't count toward the deductible on ours either. It's completely separate. They also don't count toward our max out-of-pocket. Heck even doctor visits don't count toward deductible, but do count toward max out-of-pocket.

I recommend verifying your coverages.

Also, you might check prices with goodrx, although they may not be available with Costco. Some meds are amazingly cheap using their discount.

[schildi]

Yes, I am 100% sure that prescription drugs count towards our deductible. And so do doctor visits, and pretty much everything else health related.
It seems not logical that they wouldn't, and worse with doctor visits.

I can clearly see where I am with the deductible and OOP costs on their website once I log in. And what counts towards it, which is pretty much everything. And it's been like that since 2008, when we first started the HDHP.

[jerseygirl]

Jerseyguy is waiting for a prescription from his hematologist. Can only get from specialty pharmacy and w/o insurance costs $12000/mth. It’s for chronic lymphocytic leukemia and not a highly prescribed med. Dr said she’ll work with our insurance and the company to get copay down to maybe $100/mth

Well it’s been almost 2 weeks no med yet. Called our older son a physician and told him about this. He recommended calling insurance company directly to see if the med is covered. Well did that this morning and clerk said covered and she would send an authorization form to the hematologist office.

Son said it’s awful being a physician trying to get authorization, waste of time and energy cause insurance just keeps turning down till (in the insurance company view - successfully) doctor, patient etc get discouraged and give up. Persistence and time are needed

Pharma companies are also pawns in this circus. I worked on experimental meds to get them approved by FDA etc. one drug ‘officially ‘ cost about $250000/yr
It was for a VERY rare and life threatening disease. Company made pledge that anyone who needed the drug could get it and afford it to the charity group composed of patients their families and DRs who treated them .
Most big pharma companies have programs that will give (free!) meds to people who can’t afford the med. Many don’t know about these programs unfortunately. Need to go to company website and look around. The income limits for these programs are pretty realistic . Not needing really low incomes but usually lower middle class salary. Companies give away HUGE amounts of meds. If you look at top charities for $$ many of the highest are pharma companies

Why do these pharmaceutical companies charge so much?? In the case of the med I was referencing, the cost was based on the costs of the disease - hospitalization, supplies to maintain patients life, lost wages etc
Why higher in the US than Canada? Well the US company spent multiple millions to develop the med (and lost multiple millions on unsuccessful meds). Let’s say the US company produces 5 million pills for the US market to earn back the $millions spend and lost, making another thousands pills for Canada costs almost nothing. Canada won’t buy the drug UNLESS it’s cheap even if it means patients stay sick hospitalized etc

Guess it’s certainly not ideal at all but the US makes by far most of the new drug treatments. Not Canada

System is most certainly screwed up but every year we get new meds
I was diagnosed with colon cancer last month. Until a few years ago only toxic chemo was available for treatment and not even that effective. Well I have a genetic profile that has a immunotherapy that isn’t toxic and more effective. Same immunotherapy is now used for around 30 cancers. Where was it developed? The US I am very grateful

[bean29]

I have been encountering the same issues.  I have been using Good RX and Sam's Club for most prescriptions.  I don't think we will hit the dedctible.  It is not easy to figure out how to get the best price, and for how much our insurance costs and how much we pay out of pocket, we should not have to play games like this.  

I had my Dr. prescribe Premarin.  I got the one prescription, that was the first one that I realized it was cheaper to fill outside my insurance by over $50.
Then I got home and realized they had not filled the Estrogen side of the 2 pill prescription.  First time I called about it, they denied there was a second prescription, then I read the Dr's notes, and sure enough there were 2 prescriptions.  They put the second on "hold" b/c it was so expensive.  I managed to find a coupon to get it cheaper.  Then I had them transfer another one to Meijers so I could use Good RX.  Now I am thinking that prescription, and my Syntroid are probably free if I fill at Sam's club.  Last year Sam's club was "in network" now it is out of network.  If Congress was not able to accept Bribes for Lobbyists and then we might get Better Health care options.

[jerseygirl]

The Pharmacy Benefit Mansgement Companies PBMs are the middle men between the pharmaceutical companies and the patients. These companies have formularies that list the drugs covered. If the PBM doesn’t get enough meds filled by your local pharmacy then the local or chain pharmacy might lose access to the formulary . The PBMs make millions on ‘discounts’ that neither the pharmaceutical company nor patients get.

Insurance companies and these PBCs are making millions and not really helping the US healthcare system. Just squeezing money out fro patients, doctors, hospitals etc etc

Lots of lobbying and paying senators congress etc
Also these companies employ huge numbers of people so dies our government worry about lost jobs?

[seriousthistime]

For prescription drug coverage, I don't even get an Explanation of Benefits (EOB) from my insurance.  I couldn't say if it goes to my deductible or not.

GoodRx does work with Costco. 

[daisylu]

Since we are 100% responsible for total prescription costs until we met the insurance deductible, it counts toward the deductible.

[Opti]

May 10, 2023 15:46:53 GMT -5 jerseygirl said:

The Pharmacy Benefit Mansgement Companies PBMs are the middle men between the pharmaceutical companies and the patients. These companies have formularies that list the drugs covered. If the PBM doesn’t get enough meds filled by your local pharmacy then the local or chain pharmacy might lose access to the formulary . The PBMs make millions on ‘discounts’ that neither the pharmaceutical company nor patients get.

Insurance companies and these PBCs are making millions and not really helping the US healthcare system. Just squeezing money out fro patients, doctors, hospitals etc etc

Lots of lobbying and paying senators congress etc
Also these companies employ huge numbers of people so dies our government worry about lost jobs?[img src="https://i239.photobucket.com/albums/ff155/JiminiChristmas/ymamsmiles/idunno.gif" alt="" class="smile" src="//storage.proboards.com/forum/images/smiley/huh.png"]

Thanks! Too tired, could not remember the word formularies. 

[raeoflyte]

I just ran into the same thing. The pharmacist was pushing me to use the discount plan because it was cheaper but I knew we had or were close to meeting our deductible. When they finally ran it through insurance the price came down to $25 copay. So glad I spoke up, but I need to go back through our records. I wonder if we've been overpaying when we don't realize the pharmacy isn't running rx through insurance.

[jeffreymo]

May 10, 2023 14:15:04 GMT -5 schildi said:

So ... we are on a high deductible plan, and I just got a prescription for a cream against some warts on my left hand.

Anyways, as the pharmacy, we are using Costco. So I just called them, and the prescription is ready, but:
If I go through the insurance, my copay is $188. If I just buy it from Costco directly, bypassing the insurance, then it's $76.   Wondering why the insurance would make it more expensive.

That's crazy in itself IMO, but here is another funny thing about it: I will most likely still go through the insurance and pay $188. Reason is that in this case, it counts towards our deductible, and I am very sure that this year we'll reach the $4k limit, after which the insurance pays 90%, and we pay only 10%.
So by my calculation, we'll reach the limit earlier, and since we'll reach it anyways (most likley), getting the cream for $188 with the insurance involved will only really cost us $18.80.

Does that make sense? I think the system is weird.

I went through something similar and I think my wife was shocked at a cost and so the pharmacy noted on the account to find least expensive option. Towards the end of the year when we would normally hit our deductible I found out that there weren’t any pharmacy claims.

[scgal]

We have a high deductible plan and everything goes to our deductible of 3k. I am only on 1 med that is 900 a month I don't mind paying it since after the 3k everything is 100% covered. Last year the pharmacist said they have a coupon that I could use without the ins for 700 I told them no they looke at me like I had 2 heads.