Why Your Pharmacist Can’t Tell You That $20 Prescription Could Cost Only $8

[somarco]

This years classic call. "This new eye drop is killing me. Its $100 a month. I need to switch from Silver Script"
Told her that didn't sound right. Its a $20 RX at CVS.
Client: "I go to Walgreens"
Daughter (who is on the call):" MOTHER. Jenny told you to take all new prescriptions to CVS, in case they are expensive."
Client: "Its a pain to go across the street"

This is a George Carlin routine, right?

How is it possible to say when one will be in and out of the donut hole without knowing the retail price of the drug in question?

The Rx reports on Mcare.gov show the retail prices for your plan. I suppose you can get them from your carrier as well. Never had to ask.

When I run a PDP report for clients we go over the month by month report showing retail and what you pay. The complicated ones with deductibles and hitting the donut hole take more time, but the info is there.

 

[kgmom219]

You separated your example from op's post, the other agent did not. I stand by what I said in regard to that post.

And, How is it possible to say when one will be in and out of the donut hole without knowing the retail price of the drug in question?

Well. I JUST DID ONE.

Client is on 4 meds. Lisinopril, Metformin, Glimipirde and Novolin 70/30.

Monthly cost of the first 3? $9 total.
Novo comes in at $140 per month, $47 copay.

Except she can get it via goodrx at $24 per vial.

Told her what we were doing and why. She's going with SS, oral meds under Part D. Novolin via goodrx.

In this case, even when she is in the coverage gap (which, if her meds don't change, she won't be) she is still in better shape using goodrx. If for some reason she gets to catastrophic coverage, she will still be in better shape by using goodrx. ($24 vs $28)

Its client specific, every time.

 

[LostDollar]

The Rx reports on Mcare.gov show the retail prices for your plan. I suppose you can get them from your carrier as well. Never had to ask.

I only asked because when I went to review about PDP and donut hole, it appears that the accumulation of plan's retail prices for the drugs purchased, not the accumulation of the copay/coinsurance amounts for the drugs purchased, is what carries one to the donut hole.

I assume, but don't know, that the medicare plan finder factors that in when one puts in a list of 10-15 drugs, and that one then has an annual medicare drug cost composed of deductible, initial coverage level, donut hole and the catastrophic level which can be compared to annual cash costs. Again assumptions, but I am assuming that something like that is how you got from $24K (ma plan) to $7K to >$3K in the example you cited recently.

 

[somarco]

According to the Centers for Medicare and Medicaid Services (CMS) the Standard Medicare Part D Prescription Drug Plan, the Donut Hole phase of your Medicare Part D coverage begins when your total retail drug costs reach $3750.

How does this Donut Hole really work?

you got from $24K (ma plan) to $7K to >$3K in the example you cited recently.

First I ran client drugs looking at cost for the MA plan she had applied for.

Then I ran same list but looking at only PDP

The projected annual costs is the same regardless of whether you look at the initial summary (Your Plan Comparison) showing monthly milestones or the actual monthly cost of each drug (Plan Compare). Both reports include copay's, deductibles, donut, cat, etc.

MA report results look slightly different so you need to know how to find what you need to get the answers.

In her example, all drugs were entered in the MA plan finder and again in the PDP finder. Initial run came out @ $7k for the PDP. By shifting a couple of drugs out of the PDP and over to GoodRx she got to $3k.

This isn't rocket surgery but does require an understanding of how to read the Mcare.gov results

 

[Todd King]

I only asked because when I went to review about PDP and donut hole, it appears that the accumulation of plan's retail prices for the drugs purchased, not the accumulation of the copay/coinsurance amounts for the drugs purchased, is what carries one to the donut hole.

I assume, but don't know, that the medicare plan finder factors that in when one puts in a list of 10-15 drugs, and that one then has an annual medicare drug cost composed of deductible, initial coverage level, donut hole and the catastrophic level which can be compared to annual cash costs. Again assumptions, but I am assuming that something like that is how you got from $24K (ma plan) to $7K to >$3K in the example you cited recently.

That is correct. Now, how is all of this kept up with? The CMS database, not the pharmacy. If you go to different pharmacies they will still all add up.

To my understanding, the pharmacist HAS to report any scripts filled to your Part D plan, which I assume is done via your SSN.

 

[kgmom219]

That is correct. Now, how is all of this kept up with? The CMS database, not the pharmacy. If you go to different pharmacies they will still all add up.

To my understanding, the pharmacist HAS to report any scripts filled to your Part D plan, which I assume is done via your SSN.

Nope.

At least not in CA or TX. There may be some state regs. And they don't use the SSN/Medicare Number. The Part D plans generate a unique ID number.

Medicare has zero oversight on Pharmacists. That's all state law.

Pharmacists have a DEA number, but that's the DEA. Not Medicare. (I'm trying to remember if anything else is Federal, but I think the DEA number is it.)

A lot of times the pharmacy may say "that's the law". But what it REALLY is the PBM contract. The government only requires a DEA number for controlled RX's. (Xanax and beyond. Not just CII''s.) However, the PBM won't process the RX without the DEA number.

Why?

So they can report back to the drug companies which docs are writing their meds. Then the drug companies can bonus their reps. Yell at reps whose docs aren't writing enough. And which docs are invited to the conference in the Bahamas to learn about their drugs. All expense paid, of course. (And if ANYONE tries to tell me this isn't happening anymore, please call me. I've got a bridge to sell you)

 

[VolAgent]

So they can report back to the drug companies which docs are writing their meds. Then the drug companies can bonus their reps. Yell at reps whose docs aren't writing enough. And which docs are invited to the conference in the Bahamas to learn about their drugs. All expense paid, of course. (And if ANYONE tries to tell me this isn't happening anymore, please call me. I've got a bridge to sell you)

It ain't what it use to be, but yes this is all closely tracked. My friend gets so much to spend per six months. At one point, it was larger than his salary and he was expected to spend it all, to the point of being written up if he didn't. Now it is much smaller, but he still makes sure to reward the offices that write his drugs. They get the lunches and plenty of samples. Those that don't, don't.

No idea on the trips, he doesn't talk about it but I'm sure there are still some. But there is also money for studies and papers, etc. Again, that goes to those who write the drugs.

 

[Todd King]

Nope.

At least not in CA or TX. There may be some state regs. And they don't use the SSN/Medicare Number. The Part D plans generate a unique ID number.

Medicare has zero oversight on Pharmacists. That's all state law.

Pharmacists have a DEA number, but that's the DEA. Not Medicare. (I'm trying to remember if anything else is Federal, but I think the DEA number is it.)

A lot of times the pharmacy may say "that's the law". But what it REALLY is the PBM contract. The government only requires a DEA number for controlled RX's. (Xanax and beyond. Not just CII''s.) However, the PBM won't process the RX without the DEA number.

Why?

So they can report back to the drug companies which docs are writing their meds. Then the drug companies can bonus their reps. Yell at reps whose docs aren't writing enough. And which docs are invited to the conference in the Bahamas to learn about their drugs. All expense paid, of course. (And if ANYONE tries to tell me this isn't happening anymore, please call me. I've got a bridge to sell you)

Okay, I can't honestly say I'm up on how it all works. I asked a pharmacist once how they dealt with Part D and if the client had to actually file it under Part D or not. He told me there was no way around it being reported under their Part D plan unless they filled it outside the US, like Canada. I just took his word for it. Maybe I shouldn't have!

 

[kgmom219]

Okay, I can't honestly say I'm up on how it all works. I asked a pharmacist once how they dealt with Part D and if the client had to actually file it under Part D or not. He told me there was no way around it being reported under their Part D plan unless they filled it outside the US, like Canada. I just took his word for it. Maybe I shouldn't have!

Should have made your high school and college job a pharmacy tech. Can you build a time machine?

We all have our strengths and experience. Drugs are mine.

 

[Todd King]

Should have made your high school and college job a pharmacy tech. Can you build a time machine?

We all have our strengths and experience. Drugs are mine.

I could get better at understanding it and really should since we're an IMO (but I don't push Part D), but in all honesty, I think Part D is just a scam between the Gov't and the Drug companies despite what they would like for you to believe. Part D is voluntary? MY ASS! How is is voluntary when you'll be charged a penalty if you don't take it when they say you are supposed to. Even if you don't take any drugs at the moment they still want your money.