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Beacon Senior News

A money-saving question for your next pharmacy visit

Dec 22, 2021 04:31PM ● By Arthur Vidro
Pill with money on the left and a blue RX on the right

There’s one question every consumer should ask the pharmacy when making the initial purchase of a new prescription. But we tend not to ask questions. We just slap down our cards and wait for a computer to tell the pharmacy how much money to collect from us.

Earlier this month, I was given a new prescription by my doctor. If it proves helpful, it’s something I might take perennially. Unfortunately, until you get to the pharmacy, you probably won’t be told how much the drug will cost, how much your health insurer will chip in for it or how much you’ll be expected to pay out of your pocket. The prescription might even go directly from doctor to pharmacist electronically, never being placed in your hands—which means you won’t even know how to spell the darned drug.

I don’t like surprises at cash registers. I prefer to know my costs long before I reach the checkout. But with the pharmaceutical industry, there’s no way around it because the cost comes from the insurance company and it varies greatly from one insurer to another. 

So I went to the local mom-and-pop pharmacy to get my first month’s dosage of this drug. Though I didn’t know it when I entered the shop, there is a generic version available (doctors don’t automatically mention these things). Therefore, the purchase would cost me much less than I had feared—about $22 and change out of my pocket for a month’s supply, said Carl the pharmacist.

But before paying, I asked Carl the one question that all consumers should ask when starting a new prescription: “How much would it be without the insurance?”

Normally you can expect a great difference in drug costs between a person with health insurance and a person without. That difference could get magnified manyfold if there is no generic version of the drug available.

As a rule, the cost via insurance is lower—sometimes considerably lower—or there is no difference at all. Ah, but every once in a while, the consumer with no insurance at all, or the consumer with just a freely dispensed drug-saving card that some pharmacies honor and other pharmacies choose not to, pays less than a consumer using expensive insurance. (Don’t ask why. There’s no rhyme or reason to the pricing of drugs.)

Carl happily obliged my request by researching the answer. Without insurance, the cost would be $13.50 which, you’ll note, is about $9 less than the rate for purchasing the very same drug—in the very same dosage, in the very same quantity, and at the very same pharmacy—than if I were to have the purchase processed through my health insurance.

“Oh, dear,” I said. “I seem to have left my health insurance card at home. Would you mind ringing this up without applying insurance?”

Carl obliged me.

I’ve asked around. It seems that until roughly two years ago, pharmacies were not permitted to alert you upfront on those occasions when it would cost you less if you circumvented the insurance. They were under a type of “gag order” implemented by some of the pharmacy benefit managers that act as a sort of subcontractor for the health insurance providers. However, if you broach the subject, the pharmacy is required to answer your question.

So let’s take a step back and think this through.

Every month, Anthem Blue Cross and Blue Shield receive $784.98 in exchange for providing me with health insurance through the Affordable Care Act. I am self-employed so there is no employer providing me with any benefits at all. That $784.98 is paid partially by me and partially by the federal government (everyone’s tax dollars). By the way, Anthem receives an additional $784.98 each month for providing identical health insurance to my wife.

In exchange for that $784.98 (and another $784.98 for my wife) that it receives every month, Anthem Blue Cross and Blue Shield has decided that the end customer should be charged more money for this particular purchase than if that customer had no insurance at all. Which makes the insurance seem rather valueless.

You can’t make this stuff up. But that’s our meshuga health care system. So when you initiate a new prescription at the pharmacy, ask the question: “How much would it be without insurance?” If you don’t ask, you might never know.

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