Explain to me how RX Insurance works……

[joelbc1]

I have on particularly expensive RX I use to treat my skin cancer issues. It’s called “fluroroacil” or some such thing…it’s a crème and with my MediCare/RX insurance it costs Around $160/ tube…..
If I use a “RX drug app” I can get the same med, filled by the same pharmacy for $46/tube….
Why the price difference….where does the money go and to whom?
I’m old…be patient….can anyone who knows, explain?

 

[HawCory]

I have on particularly expensive RX I use to treat my skin cancer issues. It’s called “fluroroacil” or some such thing…it’s a crème and with my MediCare/RX insurance it costs Around $160/ tube…..
If I use a “RX drug app” I can get the same med, filled by the same pharmacy for $46/tube….
Why the price difference….where does the money go and to whom?
I’m old…be patient….can anyone who knows, explain?

It seems you have the wrong prescription coverage for that particular cream, OP.
It took me all of 2 minutes on Medicare's website to find that cream for $23.06 at Walgreens or $20.95 at CVS using the Cigna Saver Rx PDP.

This, obviously, isn't the whole story because I have no idea what other prescriptions you are taking.

In short, you need to start from scratch every year during the October 15 - December 7 AEP and shop around for prescription coverage that is most suitable for your Rx list and pharmacy.

 

[alaskanseminole]

RX insurance typically works by negotiating prices with pharmaceutical companies, pharmacies, and sometimes through pharmacy benefit managers (PBMs). These negotiations determine how much the insurance company will reimburse the pharmacy for dispensing a particular medication. In your case, your Medicare/RX insurance has negotiated a price of around $160 per tube of flurouracil with your pharmacy.

However, when you use an RX drug app, you might be tapping into a different pricing system. These apps often offer discounts or coupons that can significantly lower the cost of medications.

 

[joelbc1]

It seems you have the wrong prescription coverage for that particular cream, OP.
It took me all of 2 minutes on Medicare's website to find that cream for $23.06 at Walgreens using the Cigna Saver Rx PDP.

This, obviously, isn't the whole story because I have no idea what other prescriptions you are taking.

In short, you need to start from scratch every year during the October 15 - December 7 AEP and shop around for prescription coverage that is most suitable for your Rx list and pharmacy.

That is exactly what I do…..the plan I have with the meds I use daily, all “generics, ( but a bunch of them) the RX plan costs my $6/a year. My meds are all N/C and the plan I use charges me 50 cents a month….
My question is why does thos med cost so differently depending on the insurance….,and how does the pharmacy get reimbursed based on the price variance?
(BTW…..I would never allow my shadow to darken a Walgreen’s doorway. Walgreen’s and Nixon are two reasons the RX medicine business id so messed up today)

Again,my question is more about how (much) the pharmacies get reimbursed through this what appears to be rather complicated and confusing process?

 

[BelemNole]

Where does it go? To the pharmacy bros!

 

[HawCory]

That is exactly what I do…..the plan I have with the meds I use daily, all “generics, ( but a bunch of them) the RX plan costs my $6/a year. My meds are all N/C and the plan I use charges me 50 cents a month….
My question is why does thos med cost so differently depending on the insurance….,and how does the pharmacy get reimbursed based on the price variance?
(BTW…..I would never allow my shadow to darken a Walgreen’s doorway. Walgreen’s and Nixon are two reasons the RX medicine business id so messed up today)

Again,my question is more about how (much) the pharmacies get reimbursed through this what appears to be rather complicated and confusing process?

I see.

The Wellcare Value Script plan that you have has a formulary geared more toward your generic prescriptions and discourages use of a lot of those non generic prescriptions by inflating that negotiated retail price(see @alaskanseminole 's post).

Just an FYI, be prepared for higher prescription costs, in general, in the next few years. The changes made to Part D that went into effect on January 1 of this year(particularly the cap of $8000 on Rx costs) are going to shake that industry up, imo.

 

[stout1]

Specialty medication is such a profit center that we have excluded it and have a multiple step process for a member to even use it.

Through February of this year the plan I am the trustee for has had 324 claims.
281 generics, average cost to plan $4.12
41 Brand name, average cost to plan $118.26
2 specialty drugs, average cost to plan $7,523.91

I have 3 members who have asked for waivers for drugs that will cost the plan $48k/year, $58k/year and $280k/year. I will probably get a dozen more requests through the end of the year.

 

[joelbc1]

I see.

The Wellcare Value Script plan that you have has a formulary geared more toward your generic prescriptions and discourages use of a lot of those non generic prescriptions by inflating that negotiated retail price(see @alaskanseminole 's post).

Just an FYI, be prepared for higher prescription costs, in general, in the next few years. The changes made to Part D that went into effect on January 1 of this year(particularly the cap of $8000 on Rx costs) are going to shake that industry up, imo.

Back in the day, my dad was a pharmacist who had an independent store…..50’s into the 80’s…..I was pretty famikliar with his “pricing” as he basically marked up RX meds 10% and added a $1-$2 “professional fee” per script he filled…..and that was long before there was RX insurance….Now dad was an avowed Roosevelt Democrat who vehemently opposed RX insurance…..His argument was the retail pharmacy was a gatekeeper to pricing of RX drugs but if Big Phamacy and corp[orate America ran things via “RX insurance” many users would not be able to afford the co-pays….Dad opposed WALGREEN’S marketing strategies and Richard Nixon, because Nixon advocated “corporate BIG Pharma”….and Walgreen’s (Osco at the time, too) were big proponents of this idea…..and once BIG PHARMA got control of pricing, RX prices would sky-rocket. It also meant that the day old “the independent pharmacy” was measured.
Turns out, then old man knew exactly what he was talking about…..Used to be the pharmaceutical reps called on the drug stores and pharmacistsd to “hawk” their business……not any more….they go right to the docs, their offices and the hospitals!