My insurance will be switching to a high deductible plan, with no co-pay plan for prescriptions. Any prescriptions will apply to the deductible. My question is regarding how the cost of the meds will be determined.
I picked up a prescription for acid reflux medicine at Walgreens yesterday. My current co-pay plan it $10/$25/$50 depending where on the formulary the medicine falls. If the drug costs less than $10, we are charge that amount. The cost for this prescription was $8.34. On the print out from Walgreens, it has in small writing: Retail price $203.99 Insurance saved you $195.65.
So, when January rolls around, will this medicine still cost $8.34, or will it be $203.99? How can I find out the amounts we will be paying for other prescriptions that are currently limited to $10 now? Thanks for your help!
You can find out by calling up your insurance company and asking them. You might want to call more than once, if you think their representatives are poorly informed about their company policy.
I don’t know who the insurance company will be yet. Our company was bought by a company in another state. We can see their current plan on their portal. We will be moving to a similar plan, but with a different carrier, since their plan does not have any providers in our area.
Generally, does anyone have this type of plan, and how are your meds priced (as in the $8.34 example)?
Your insurance company will have negotiated prices for the various drugs. You will pay that price, not the “list” price. It will apply to your deductible, so if you have a chronic requirement you’ll blow thru the deductible rather quickly. Then your coinsurance should pick it up I.e. 80/20%. After your max is reached it should be no cost.
Thank you @yourmomma Glad to learn they will have negotiated prices. Their current plan has a max out of pocket of $6k. That is a pretty scary number.
We have this problem and for some medications the cost is astounding. My girls both use epi-pens and in the past it had been over $300 for one two pack. The price has come down, but its still over $100. I recently had to pay over $80 for eye drops for an eye infections. Our insurance is atrocious.
I’ve tried to ask the same question and for some reason, nobody, including my pharmacy and insurance company, can tell me how much prescriptions would cost. It’s infuriating.
Download the GoodRx app. That allows you to search for coupons that give a discounted cash price at various pharmacies. It doesn’t count against your deductible but in some cases can be much cheaper than the negotiated insurance rate. We have a high deductible that we never reach so for one regular prescription we just use the GoodRx rate (~$115/mo) instead of paying the insurance price of $174/mo.
I agree that this is unknown and unknowable, both for prescriptions and for other medical care. I had some testing done recently, and the hospital told the insurance company what billing codes they’d be submitting and got the cost estimate for me up front. The actual EOBs came in 50% higher. Instead of the $400 I’d been quoted, it was $650.
ETA: my prescriptions cost a different amount every month, it seems like. Insurance plan years don’t align with the periods for which prices are negotiated.
RX coverage is weird! I am on Medicare and have express scripts for RX. My card clearly states that generics will be $5 copay after the Medicare deductible for RX is reached (I think that’s $400 or so this year). I have reached that deductible.
I picked up two generic RX this week. One was $8.34 and the other was $3.50. Both had retail costs of well over $75.
Whatever.
Hopefully your insurance won’t be like the plan we had. Advair was $220/month - and that was the negotiated price! We had CVS/Caremark and if we went somewhere like the Costco pharmacy, the medication may have cost less, but wouldn’t count towards our deductible.
I do sympathize with the frustration of not knowing how much prescriptions will cost. My son was told by one doc that we should research very-new-designer-drug AA. She said she would work with the insurance company to get it approved. (Because all new designer drugs require a huge uphill battle.) AA’s MSRP is roughly $3700/month. I called insurance co to find out what my cost would be. They can’t tell me until I get approval for it. I told them I don’t want to waste their time trying to get approval for it until I know it’s something I can actually afford! The response was I’d just have to fight for approval to get that answer. Geesh! No wonder costs keep going up.
It is until you look at the premium savings. It just pushes the costs up front – pay if you use – instead of paying “in case” thru higher premiums. For the average person who buys 1 or 2 prescriptions a year, it’s no big deal. For someone with chronic issues and monthly prescriptions it takes some planning. You need to do some math to determine the effects. You know your max out of pocket and you can hit that very quickly.
@uwalummom Is your plan HSA eligible? It sounds like it.
That’s because we have been conditioned to believe that medical costs are $10/$20/$30 or similar. The true costs have been “hidden” from the user.
And it is clear that the consumer is frustrated because we can’t determine the costs for simple things. The providers need to change, and will be forced to by the consumers. There is nothing more powerful than the consumer for controlling costs.
Alternatively, the inflation of costs has been hidden from the user. In countries that have single payer, overall costs are lower.
Note that “deductible” and "out of pocket maximum are two different things.
The deductible is what you must pay before the plan starts to pay anything – e.g., its 80% or 90% or whatever.
The out of pocket maximum is the total amount you must pay during the year. After you reach that amount, the plan pays everything at 100%. The out of pocket max might include the deductible or it might not; call your HR Department or your insurance company to find out.The out of pocket max definitely includes the 10% or 20% portion that you pay after you’ve reached the deductible.
Also note that you do have a drug plan. You will receive the insurance discount when you purchase your drugs; however, you’ll be paying that entire amount until you reach the deductible.
The happy dream says giving people higher deductibles, thus giving them “skin in the game,” will make them better shoppers for health care. Sadly, this hypothesis has been tested, and there is no evidence it’s true. It seems like it would be true, but evidently it isn’t true.
If people have to pay more, they will reduce their health care spending a bit, but not by eliminating lower value care or shopping around for necessary care. They just reduce care across the board, which is not what we want. We want people to stop getting unnecessary back surgeries and shop around for good prices on knee replacements, but that doesn’t happen. Instead they skimp on unnecessary care (like back surgery) and necessary care (like insulin) alike.
Possibly shopping for health care is too complex and confusing for most people to be able to be smart shoppers.
We have not had much luck finding out how much a prescription will cost if we were to change to another plan. We hate our current insurance as far as the medical side goes and would like to change to another plan. However, the current plan is fantastic as far as prescription coverage. Our DS2 uses a med that would cost $8,000 per month but for which we pay $250 per month after insurance and then down to $50/month after a manufacturer’s assistance program. I have called the potential new plans countless times and can get no guarantees of what our cost would be or even if they would cover it. He has 3 more years to stay on our insurance and is very aware that he will have to consider health insurance plans when he goes job hunting after grad school. Yikes.
It’s always a surprise ( usually not a happy one). We’ve had high deductible plans for many years. Usually they give you the discount ( by this I mean that if the drug costs $500 and the insurance cost is $125, you would pay $125) but all of them work differently. We have never had a company that allowed drugs to be used towards the deduction. It was only billed healthcare that was calculated. We have one now which pays big bucks for drugs which are common ( so a $500/month drug which my spouse takes is covered) but an acne cream that is uncommon is not. GoodRX as suggested above is a godsend. So is contacting the drug company which can sometimes offer a limited time deal or reduced cost based on income.
The other thing to remember, AFTER they tell you how much it is with insurance, ask how much it would be if you paid it fully. It can be less. Crazy. This is especially true at Kmart, Target type stores. Some of their common things cost $5.00 or something very low. Once I said, ok I’ll just pay for the acne cream. The lady looked at me and with a straight face said are you sure, that would be $1185.00? OK, nope. I’ll pass.
We are lucky not to have too many prescriptions. I really feel for the folks who have to fork out thousands monthly just to keep their family healthy.
Right now, we’re trying to get prices for Amicar, a blood clotting med, for my son in Lebanon. It will be fascinating to see what it costs there. Here, the ticket price is $2,500 per dose, but we were able to get assistance for my D in January and got it for $60.
If we end up with something similar to what the new company’s employees have, our premiums will double, deductible will increase from $1000/family to $2700/family, and the max out of pocket will increase from $2000/family to $6000/family. Plus no more drug co-pay plan.
@yourmomma yes, I think there will be something about an HSA, but I can’t see anything where the employer puts anything into it unless you earn a certain amount of wellness points in a quarter to earn $150 deposit into an HSA.