WARNING – You may be paying more for your prescriptions when using insurance at the pharmacy
Kudos to Anne Thompson of NBC News for pointing out a secret practice in the pharmacy industry that is costing insured consumers more money at the pharmacy when using insurance instead of paying cash for their prescriptions.
The Dirty Little Secret
Insurers, like United Health Care and Cigna, use the prescription benefit manager (PBM) OptumRx that may charge its members more at the pharmacy than if they paid for their prescriptions WITHOUT using their insurance.
NBC news gave an example of the practice and pointed out that the pharmacists are bound by a gag clause in their PBM contracts NOT to inform patients that they are overpaying for their medications when using their insurance cards.
[PBMs contract with pharmacies on behalf of the insurance companies to gain leverage to control costs on prescription medications. In order to participate in the PBM’s pharmacy network, the pharmacies must abide by the contract. One clause in these contracts, known as the gag clause, forbid the pharmacist from telling the insured customer that the pharmacy’s cash price (the price WITHOUT insurance) is less than their copay when using insurance.]
One example from NBC News – An insured patient using the popular generic drug Simvastatin, used to control cholesterol, paid an insurance copay of $42.60. That exact same prescription filled at this pharmacy WITHOUT using insurance only cost $18.59 – a $24.01 difference. That’s a large penalty the insured member paid to use their insurance. Isn’t the point of insurance to reduced your overall costs?
How to Avoid being Overcharged
It’s important to know that there are 3 price options when purchasing prescriptions at your local pharmacy when you have insurance:
- The insurance medication copay price (your portion of the cost when using insurance)
- The pharmacy’s cash price (the usual and customary (U&C) price the pharmacy charges)
- The discount card price (the discount price off the pharmacy’s U&C price)
First, as stated in the NBC News segment, always ask your pharmacist if the price you are paying with your insurance card is the lowest price. By asking, the pharmacist is no longer bound by the gag clause and they are free to divulge their cash price if it’s lower than your insurance copay. By asking however, the pharmacist is only comparing your insurance copay with their cash price. There is another option they may be missing.
EasyDrugCard uses a pricing methodology known as “lower-of” pricing. This guarantees you’ll always pay the lowest price when using our card! Lower-of pricing compares the pharmacy’s cash price with the EasyDrugCard’s discount price and only charges the lowest price for the medication. If the cash price is lower than our discount card price – you pay the cash price automatically.
The same holds true on most insurance however OptumRx (the PBM that calculated the prescription price) has this feature turned off for United Health Care and Cigna.
How Does EasyDrugCard Guarantee the Lowest Price?
EasyDrugCard functions the same way as insurance cards when pricing medications at the pharmacy. Both calculate the price of the medication based on their agreements with participating pharmacies. The calculated price is normally lower than the pharmacy’s cash price. The only difference is, your insurance might only charge you a portion of the total cost (your copay) while they pay the balance.
With our discount drug card, you pay the entire discounted price yourself – there is no insurance to pay the cost above your copay.
In the example above, the pharmacy’s cash price for Simvastatin was $18.59. Since the NBC News segment did not say what the quantity or strength was in their example it is impossible to get an actual discount card price however, we priced a 90-day supply of Simvastatin 80mg (this is the highest dose of Simvastatin for the longest time period) on our website EasyDrugCard.com at Magnolia Pharmacy for a discount price of $11.83. That is a savings of $6.76 off the pharmacy’s cash price.
So, to further the example in the NBC News segment:
$42.60 – Member’s insurance copay
$18.59 – Magnolia Pharmacy’s cash price
$11.83 – EasyDrugCard price
If the drug strength or the days’ supply was less, the discount drug card price would have been even lower.
How to Pay the Lowest Price
Let’s revisit the “lower-of” pricing methodology mentioned previously. Had the pharmacy’s cash price been lower than our discount card or insurance price the member would have paid the pharmacy’s cash price automatically since we use “lower-of” pricing during adjudication of the prescription claim.
In the NBC News segment, if the PBM used “lower-of” pricing, the member would have paid pharmacy’s cash price of $18.59 but, as you can see, there’s an even lower price available – the our discount drug card price of $11.83.
Use EasyDrugCard to guarantee you always pay the lowest price at the pharmacy – EVEN IF YOU HAVE INSURANCE!