Retail Price for Prescription Drugs

[healther]

Might need your thinking cap for this one...

Had an appointment yesterday and the client asked me when they would hit the donut hole.

Prescription: Quetiapine
Current PDP retail price (in-network pharmacy): $54 co-pay $38
Proposed MA retail price (in-network pharmacy): $233 co-pay $6
Actual retail price at the same pharmacy: $670

My question is... How are the retail prices for the prescription determined? I called Medicare and the plans and nobody could provide an answer.

Obviously this is a very important question since the retail price of the prescription determines when they will, or if they will, reach the donut hole. On the current plan, they will not. On the proposed plan they would reach it in Sept. The decision was a "no-brainer" to leave things be and avoid the donut hole, but how can there be such a discrepancy between the retail prices?

 

[Guest]

how does one grocery store sell milk for 3.59 and another for 4.25?
I advise my customers to always shop their prices in January and then decide to use the pharmacy with the cheapest prices.
Each pharmacy sets there own prices (I worked in a pharmacy for many years) we would call around and shop also and we would adjust our prices every 6 months to stay competitive.

 

[healther]

how does one grocery store sell milk for 3.59 and another for 4.25?
I advise my customers to always shop their prices in January and then decide to use the pharmacy with the cheapest prices.
Each pharmacy sets there own prices (I worked in a pharmacy for many years) we would call around and shop also and we would adjust our prices every 6 months to stay competitive.

It's not the pharmacy. I confirmed the retail price from the plans, regardless of pharmacy, and they confirmed the total price of the prescription that would be used toward ascension to the donut hole.

 

[AllGold]

Plug the drug info into medicare.gov and it will show you exactly for each plan you're considering.

 

[0b1kanobee]

Just curious since I'm new to MA but if someone were to be able to buy a drug outside the plan through some means when they are in the doughnut hole, does the money they spend count towards their TROOP? I'm under the impression it would not and I'm not even sure this is a consideration. It just had me thinking when I was studying all this information.

 

[Guest]

Just curious since I'm new to MA but if someone were to be able to buy a drug outside the plan through some means when they are in the doughnut hole, does the money they spend count towards their TROOP? I'm under the impression it would not and I'm not even sure this is a consideration. It just had me thinking when I was studying all this information.

If its not processed through the drug card then the it does not count toward troop.
I find if my customers are in the donut hole after the middle of the year it is more cost effective to shop Canadian drugs, if of course they wont come out of the hole by the end of the year.

 

[SportsNut]

My question is... How are the retail prices for the prescription determined? I called Medicare and the plans and nobody could provide an answer.

how can there be such a discrepancy between the retail prices?

Purchasing power of large Rx PDP company.
Aggressive pricing to attract new member beneficiaries.
Lack of competitiveness on the part of many plans; they do not have their eye on the ball.
Certainly other factors too, hard to list all of them.

Playing around early into the AEP and comparing Rx plans for current clients, I did a comparison of the PDP plans while checking only one company, instead of comparing multiple companies. When you do this it will then display additional information about the retail cost of the Rx within that company, the cost of the specific Rx while in each phase of coverage: Deductible, Initial Covg, Donut Hole, Catastrophic. Thought it was pretty slick and I now do that for many of my clients who seem to be more detailed want more data, for the specific plan that they will ultimately be on for 2013. This would allow them to get the printout out during the year as they cost of the Rx changes and see exactly why and what they should be paying. Thought it was pretty decent info that I wasn't previously aware of.

 

[somarco]

PBM's determine pricing, formulary's and tiers for Rx plans. Pharmacy buying power (as indicated above) determines retail price.

Location also comes in to play.

A CVS in an upscale neighborhood might sell a drug at retail for $40. Same drug at another CVS, same city, but in the poor side of town might sell it for $60

 

[healther]

I used the neighborhood Wal-Mart for the pharmacy. How can one Wal-Mart have 3 different prices for the same prescription?

 

[SportsNut]

I used the neighborhood Wal-Mart for the pharmacy. How can one Wal-Mart have 3 different prices for the same prescription?

Simple... each WM uses a pricing structure based on the local competition... prices are based on whatever the market will bear. Same thing when WM goes into an are brand new; they sell Rx at cost to break the competition, then when the comp is gone, guess what... they reap the harvest at that time by raising prices since they have elminated the competition.

As has been said here many times, Humana is the Debil... WM is likewise the Debil.