Question: My doctor ordered a new medication for me. When I went to pick it up from the pharmacy the co-pay was pretty high. I have already met my deductible. I asked the pharmacists about it. I said “If my co-pay is this much (more than $90), how much does it actually cost?” The pharmacists answered “With insurance or for cash?” He said with insurance it was over $200, but for cash, I could get it for about $15! How can that be?

Answer: I hear this type of story so often. We like to believe that medications cost the same at every pharmacy and with every form of insurance, and with every form of payment. The world of medications in the USA is not like that. Our system is a capitalist system. The price is whatever the involved parties negotiate it to be.

I am going to give a couple of examples I have heard recently. One is the one I was given in this question. The generic medication being filled using a Medicare Prescription Drug Plan available here in Chaut. Co. was negotiated to be a pretty high priced generic medication under that plan. When speaking to the pharmacists and asking what they could buy it for without insurance it was significantly less expensive.

Another example is the insulin Novolin N, Novolin R & Novolin 70/30 and the Walmart pharmacy. If you buy these types of insulin with your Medicare Part D plan the negotiated cost for these medications is between $135 to $165 per month. Your cost share at Walmart could be $29 to $40 to full price because your Part D plan does not cover this type of insulin. If you go to Walmart and buy any of these three insulin types without insurance the cost is $25 per vial. The pharmacy is the same, the insulin is the same, the insurance (or lack of it) is the only difference.

In thinking about this situation it is important to realize that not all medications work like this. It is more common with generic medications. Most of the time your prescription drug plan is giving you the lower cost for the medications, once you are through the deductible if your plan has one.

There are also differences between pharmacies which I have covered in previous articles. Your insurance products negotiate a different full cost for the medications with different pharmacies. So when possible you want to use a preferred pharmacy.

I recently spoke to a client who looked at the difference between the standard and preferred pharmacies and the cost to them was significantly different. The Standard pharmacy was over $100 during the deductible and the preferred pharmacy was closer to $60 per month. That was during the deductible, but during initial coverage the cost can be much cheaper at a preferred pharmacy as well.

This price difference can also be true with generics, like Gabapentin, at a standard pharmacy is $15 per month and a preferred pharmacy is $6. Now that is not as big a difference, but if you could save $9 on all your meds each month all year long, it adds up.

It is important to remember that the pharmacist cannot tell you about these price differences unless you ask them directly. The pharmacist and the individuals that work in their departments are busy people. They have a significant workload and everyone wants their attention. Sometimes the person who checks you out does have the answers to your questions. You need to speak with someone who has access to more information.

Also be understanding that some days the pharmacist has more time to help and answer questions. I do not recommend going to the pharmacy right before closing time to ask questions like this. It takes a bit of time for them to access their computers and look up the information you need. Try to visit the pharmacy at quiet times of day, when they can give you the extended time you need to review these costs.

Some pharmacies offer a list of medications at a reduced cost; like $4 -30 day supplies or $10 or $12 90-day supplies. The most common we come across is Walmart & Wegmans. Some of the local pharmacies will do the same type of thing if you ask them.

There are some websites that promise the best possible price on your products (like medications). That can be true for cash, but remember your Medicare Part D plans negotiate that price using a different system.

It is important to realize that if you are buying your medications for cash, they are not being included in your Prescription Drug Coverage, so it is not moving through the different stages of coverage, like deductible, initial coverage, coverage gap and catastrophic coverage.

I always encourage everyone to ask questions. Why is my co-pay so high? Would it be cheaper if I paid cash without insurance? Look at your insurance material to determine pharmacy status (standard vs. preferred). Is there a difference in cost or significant savings if I use mail order? The more you know about your insurance coverage the better off you will be.

To contact Janell Sluga, GCMC with questions or concerns, please call 720-9797 or e-mail her at janells@lutheran-jamestown.org.