This week’s question from Donna
Why do Medicare Part D Prescription Drug Plans pretty much force people to use “Preferred Pharmacies” by charging more money for the same medications vs a Standard Pharmacy or others that are out of network all together? I don’t mind paying a bit extra, but the difference in price for the new brand name drug I was recently prescribed is enough that I can no longer go to my local mom-and-pop pharmacy. It’s very disappointing because I really like them and have been getting my prescriptions filled there for years.
Answer
I Don’t Agree with the Practice
I can’t give a definitive answer, except to say it doesn’t seem fair or very democratic in my opinion. It’s a sore spot for me. Think about this is. Part D, a government subsidized program, makes it almost impossible for local independently owned pharmacies to compete with the big chains when it comes Stand Alone Part D plans which those with Supplements must purchase. These company’s Preferred Pharmacy lists are almost exclusively made up of big chains and most mom-and-pop pharmacies are Out of Network, meaning there is no reimbursement from the insurance company. Why shouldn’t every pharmacy be able to get reimbursed the same rate for the same medications? And why should taxpayers who helped fund Part D be forced to pay more for those same drugs at the pharmacy of their choice?
As I’ve been saying for quite a long time, the entire pharmaceutical industry needs a total overhaul, starting with regulations that force drug manufacturers to sell medications to wholesalers or directly to pharmacies at the same prices they do in other countries. There’s absolutely no reason US citizens, employers, and taxpayers should be subsidizing the rest of the world’s drug costs like we are now. Any excuse you read or hear why regulations lowering wholesale pricing would be a bad thing for American citizens is insulting and a lie. The one used the most is research and development would be stifled if manufacturers were forced to lower prices in the United States, meaning possibly lifesaving medications would never get to market. So basically, this means not only are US citizens making drugs cheaper for the world, but we’re also funding the majority of the R and D. With many of the top grossing pharmaceutical manufacturers based out of Europe, this situation is even more ridiculous. Unfortunately, with money playing such a huge role in American politics, and the gazillion dollars it takes to run for the US House of Representatives, Senate, and President, laws are made to protect big donors instead of the middle class and senior citizens.
Preferred vs Standard vs Out of Network Pharmacies
Getting back to the Preferred vs Standard vs Out of Network Pharmacy topic, there are ways to continue patronizing your neighborhood pharmacy. The first is to give them a chance to come as close as possible to matching what your co-pays are at a Preferred Pharmacy. It’s almost certain they won’t be able to match all copays, as many are $0 or $1 for Tier 1 Generics, but they can possibly make them reasonable enough. A good pharmacist is extremely valuable in my opinion. Ask yourself what dollar figure you put on keeping your favorite. Is it $100 per year? $250? $500? Even $1,000 or more? In Donna’s case, she indicated it was the brand name medication that’s going to be the one to push her over that limit. What she and others can do is get their less expensive generics at the Standard or Out of Network Pharmacy and any brand name or much more expensive generics at the Preferred. Utilizing mail order or getting a 90-day supply can keep the inconvenience of running to two separate pharmacies to a minimum.
There are actually a couple of Part D plans where Standard Pharmacy prices are similar or less expensive than using a Preferred, which is crazy, but so is Part D in general. Crazy enough that taking a pill instead of a capsule of the same medication can make hundreds of dollars difference per year or taking the single use bottles of Restasis instead of the monthly vial, over a $1,000. There are so many under the radar nuances like this which can make choosing the right Part D plan confusing and frustrating even before adding in the Preferred Pharmacy drama. What people who aren’t already clients of ours can do is eliminate that stress by putting that job in The Health Insurance Store’s hands. We can work with you to make sure you get the best value in Part D, let you know if it’s financially viable to get some or all your meds at your neighborhood pharmacy, and how much it would cost. We do that for all our Stand-Alone Part D clients every Annual Election Period (AEP). If you would like to be put on our mailing list for the AEP, when people can change Part D plans, reach out to us.
I need to make it clear that being forced to use big chain Preferred Pharmacies is a much more prevalent problem with Stand Alone Part D plans than on Advantage Plan HMOs and PPOs. Two of the three most popular Medicare Advantage Plans in Western PA have very long lists of Preferred Pharmacies and most independently owned drug stores are included.
Thank you!
If you have any questions or concerns regarding this column topic, or would like to make an appointment for a no-cost consultation, please feel free to give us a call – we would be happy to help. I’d like to remind everyone that I do a live call-in talk show called Medicare A to Z every 1st and 3rd Monday of the month on WMBS Uniontown, 590AM and 101.1FM, from 1 to 3 PM. You can listen in on their website, wmbs590.com.
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