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Friday, September 18, 2015


Pharmacies have no control over the prices of prescriptions where patients use their insurance. Period.

(For the NPR article I am referencing, click here: http://www.npr.org/sections/health-shots/2015/09/16/440612238/how-to-save-money-on-prescription-drugs-insured-or-not?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20150916 )

A pharmacy cannot charge more than its Usual and Customary Charge to a patient on insurance. This means that if the cash (no insurance) paying patient is charged $45, the pharmacy cannot charge her $900 on her insurance. Many pharmacies when quoting prices, are only able to give straight cash prices and not prices on insurance without first billing the prescription to the insurance. Some companies are able to provide these prices but you must make sure what price you are receiving. A better solution would be for the patient to call her insurance and ask them. They are the ones that set the prices.

Lesson 1. Pharmacies want to build loyalty. We are a most-trusted profession. The correct response to pricing issues would be build a relationship with your PHARMACIST first. Second, READ YOUR INSURANCE EXPLANATION OF BENEFITS. If your insurance selected a preferred pharmacy, go there. If you like your pharmacist and she does not work there, pay more for her knowledge and trust. If it is cheaper to purchase 90 days at a time, ask your prescriber to write new prescriptions that way the next time you see her. (NPR got this a little wrong. You won't be avoiding copays. You'll have to pay more initially. If your copay is $30.00 for one month, it's usually $90.00 for 3 months. Generally, the only way to save copays is to use mail order which often fills 3 months for 2 copays.)
Again, trust your pharmacist. Ask her what alternatives are available. Go home and check your EOB or your insurance's online formulary (or call them) and research which of these alternatives is preferred. Call your prescriber and ask her to change it.

Lesson 2. Appeal. Good idea. But the problem is this relies on the patient actually taking control of her own healthcare. It is easier to have the pharmacy and prescriber's office do all the work than to take some responsibility.

Lesson 3. Look for Financial Assistance. Another good idea. Another problem with patients taking responsibility. The patient would have to do the research.

Lesson 4. Bad idea. This requires no effort on the part of the patient which is why it's the easiest and least effective.
Discount Cards are NOT helpful. They cannot be combined with commercial insurance.
They are a data collection scam. People who complain about privacy violations seem all too willing to let these companies have access to their personal information in exchange for an average of 10-20% off the cost of their prescriptions. If these patients are truly cash paying customers, then, and only then, should they work to find a lower cash price. Call other pharmacies for prices. Ask about their in-house discount cards. Ask if your regular pharmacy matches competitor prices. This is especially relevant when purchasing medications for pets.
(Chain pharmacies often do not have access to Acquisition Cost which is the price actually paid for the medication. Independents do. They will be better able to give you a better deal because they can see how much they need to charge to cover their costs. Chains generally only see Average Wholesale Price which can be hundreds of dollars more than the AC.)
Example: The anti nausea medication Ondansetron has an AWP of ~$700 but an AC of closer to $4.00.

Manufacturer Cards (Note: These are different from Discount Cards.) They are distributed directly by the manufacturer and are specific to their medications. They are for brand name medications as a way to reduce copays but, as correctly stated by NPR, they cannot be combined with Medicare plans or government-funded plans. Unfortunately, prescribers continue to hand these cards out to these patients.

Lesson 5. Great idea. We have been saying this for years. The only problem is it requires research by the patient. It is difficult to understand, especially for older patients on Medicare who take multiple medications, often many brands and generics. Ask your pharmacist for help before making a final decision. She can help.

Unfortunately, NPR set this up so the pharmacist looks like the bad girl. The easiest lessons are the ones over which we have no control and are the ones the patients would rather do. Because the best ideas require the most work from the patients themselves and are the most effective, few will opt for this route. We will still get yelled at and patients won't listen as we offer them alternatives.
C'est la vie...


  1. Notice how incompetent journalists are when talking about the things you are knowledgeable about?

    That's how ignorant they are about EVERYTHING, you just may not know enough about the specific subject to catch it.

  2. Notice how incompetent journalists are when talking about the things you are knowledgeable about?

    That's how ignorant they are about EVERYTHING, you just may not know enough about the specific subject to catch it.