Puget Sound Health Partners Informative - Co_Pay Higher Than OTC?

Review by Starlord on 2010-10-28
My doctor requires me to inject insulin twice a day, 50 units in the morning and 30 units at bedtime. I have discovered in Washington state, I can get my insulin over the counter at WalMart's pharmacy. Last year, I ended up in the 'donut hole', and was unable to pay 100% for my prescriptions, so I went without them for six months. This was mainly due to my insulin. When my insulin purchases went through my health insurance, my co-pay was $29.00 per vial. This year, it is almost Novemeber, and I think I will make it through the rest of the year without hitting the donut hole. When I purchase my insulin over the counter, I pay $24.88 per vial. Now, I am no math wizard, but how in the blue susie can my co-pay cost more than the price I pay out of pocket? This makes no sense to me whatsoever. When I ask about it, I am either ignored or they just shrug their shoulders.
Comments:5 Replies - Latest reply on 2011-02-06
Posted by leet60 on 2010-10-28:
This does not suprise me. The insurer is at fault here. They set a price for your copay on your prescription medications. As it happens the same prescription OTC is offered cheaper by the pharmacy at Walmart.

The insurer is trying to recover the cost of care through the copay and premiums. Walmarts only interest is profit and buying the medication in bulk and selling it at that price they still make a profit.

You might want to check to see if your insurer has a mail order program as these are usually signifigantly cheaper.
Posted by Alain on 2010-10-28:
Starlord, I sometimes see some of the pharmacy companies offering to help with perscription cost. Maybe see if some of them wouldn't be willing to lend a hand? It's worth a look.
Posted by Anonymous on 2010-10-28:
I'd actually explore this further, starting with your pharmacist, then speaking with a supervisor at your insurance company. Normally, the lower of the two charges would apply to you.

Perhaps the difference between the cost of the script and the OTC indicates there is a difference in these actual drugs (even though that difference may only be cosmetic).

You have a legitimate question, I wouldn't accept being ignored or shrugged at.
Posted by Starlord on 2011-02-06:
Linus, the drug is the same, only the prices are different. I keep asking these questions, and I get a blank stare or a lot of double talk.
Posted by Anonymous on 2011-02-06:
Star, I would check with both the pharmacist and the company who provides your Part D coverage. I am not sure how it is for all, but most carriers require that the patient is charged the lesser of the following three: their normal copay. The contracted rate (the amount submitted to your insurance, but it is less than your copay so the insurance has zero balance to pay) or usual and customary price (regular cash price). The pharmacist is either billing it incorrectly (perhaps a wrong DAW code) or the PBM has something coded wrong in the way the plan is set up in the system for billing.

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