PDP Games on Retail Pricing

[somarco]

For some time now I have noticed significant retail drug pricing differentials from one carrier to the next when doing the side x side monthly cost run. I normally only look at the "Your Cost" column but when a client is going into the donut hole the Total Drug Cost column becomes important.

The total cost with carrier A may be 2x, 3x or more the total cost of the same drug with carrier B.

It occurred to me that carriers with relatively low premiums are using inflated retail (Total Cost) pricing to push policyholders into the donut hole much quicker.

Anyone else noticed this and have some insight?

 

[vic120]

I've noticed this on Med dot gov, I wasn't sure if just inaccurate and thought maybe it didn't transfer to the real world. However confusing it is when quoting someone on either tier 4,5 or specialty drugs and people hitting the doughnut hole,

Maybe you are right though maybe it does transfer

 

[somarco]

Tier pricing is another issue.

I have a lady who is "married" to Walmart. LOVES her Humana WM plan in spite of them increasing premium from $20 this year to $30 next year. Lives on a tight budget but refuses to shop anywhere but WM.

She is on 13 or 14 drugs (up from 8 this year). All are generic. Most are psych related.

Humana WM plan has many of her generics at tier 3 and 4 and much higher retail cost than other carriers.

Tried to get her to move to Wellcare. Half the premium and lower copay but WM not on their preferred list.

Also encourage using GoodRx. Again, lower copay than her H WM plan.

Not budging.

Even the Wellcare plan used lower tiers for all or almost all of her drugs. Don't recall any being tier 3 or higher.

 

[Midlevel]

I've noticed this the last few years also. One particular plan always showed way lower full prices that were lower then their actual copay would be so it showed them as the best plan for people. I never put a single person on it but the Area Agency on Aging put a ton of people on it because they don't know what they are doing most of the time.

 

[yorkriver1]

I've noticed this the last few years also. One particular plan always showed way lower full prices that were lower then their actual copay would be so it showed them as the best plan for people. I never put a single person on it but the Area Agency on Aging put a ton of people on it because they don't know what they are doing most of the time.

Would you mind explaining this a bit further? One of my clients is waiting out another year to see how Wellcare's pricing plays out. On Silver Script now, staying there, and appealing a drug they took off their formulary that was on it up to end of this year. Not a wildly expensive drug, but $100/month is something. Client is not low income.

 

[Alston]

Doesn't the "Estimated Annual Drug Costs:" column take the premium and copays and everything else into consideration (including the donut hole)? Why do the math yourself?

 

[somarco]

Doesn't the "Estimated Annual Drug Costs:" column take the premium and copays and everything else into consideration (including the donut hole)? Why do the math yourself?

The estimated annual and milestones does show totals but only the expanded copay report shows what you pay each month for each drug.

 

[Stephen]

For some time now I have noticed significant retail drug pricing differentials from one carrier to the next when doing the side x side monthly cost run. I normally only look at the "Your Cost" column but when a client is going into the donut hole the Total Drug Cost column becomes important.

The total cost with carrier A may be 2x, 3x or more the total cost of the same drug with carrier B.

It occurred to me that carriers with relatively low premiums are using inflated retail (Total Cost) pricing to push policyholders into the donut hole much quicker.

Anyone else noticed this and have some insight?

This year, I have definitely noticed an uptick in the retail costs being squirrely from one carrier to the next. Absolutely no insight to share however.

 

[Stephen]

Doesn't the "Estimated Annual Drug Costs:" column take the premium and copays and everything else into consideration (including the donut hole)? Why do the math yourself?

Alston , one reason that I have started paying attention to the retail cost column is to see if my clients may want to talk to their physician about an alternative medication.

For example , a $40 co pay drug may not draw a lot of attention. But if the retail cost is $800 - and the main reason that someone is going into the donut hole , then the effect on the total picture may warrant more research.

 

[somarco]

But if the retail cost is $800 - and the main reason that someone is going into the donut hole , then the effect on the total picture may warrant more research.

Hence the reason for my post.

When I run reports for first timer's (T65) I show them one report only (the copay "cost" report). If they are going into the donut hole I show them the expanded report so they can see their copay and how it changes from month to month.

I also show them two plans. One with a deductible, one without.

Often the no deductible plans have higher copay's. They may have higher retail costs as well. Often significantly higher.

Going from memory alone (which is dangerous), I seem to recall SilverScript and the Humana Walmart plan having higher retail pricing than most of the other plans I normally see. I also noticed the H WM plan having a number of generics at tier 3 or higher where they can get hit by the deductible.

Didn't notice it so much on the two low premium leaders in GA next year, Wellcare and Envision.