At the Pharmacy

When I ponder co-pays, wondering why the amount I’m charged at the pharmacy has no relationship whatsoever to my insurance benefits booklet, I sometimes ask why.  Why does the cost have to be a secret?  People on any insurance plan should be able to look at  their insurer’s formulary and know what their benefits will be on any given prescription.  My insurer says that drug co-pays will be:

$10 for Tier I drugs
$25 for Tier II drugs
$50 for Tier III drugs

This is not rocket science.  It is a basic second grade arithmetic problem.  Four of my family’s prescriptions this past year were for Tier II drugs.  The remainder were Tier I:  ($25)(4) + ($10)(59) = $690

Grand total out-of-pocket spent at the pharmacy last year was $575.48.  That extra $114.52?  I’m thrilled to have saved the money.

A recent commenter says,

“I am kinda confused as to why you’re complaining about an amount that is less then [sic] your copay. Do you believe that we pharmacies lower your copay on certain meds just so we can “overcharge” you on others? I’m sorry to be rude, but that’s complete BS…like I already mentioned…WE DO NOT SET COPAYS…that is done by your insurance company after we submit a claim.”

The pharmacy tech who wrote the comment is wrong.  Insurance companies do not set co-pays after a claim is submitted.  Co-pays are defined in a legal contract long before any prescriptions are ever written.  When a claim is submitted, the insurance company doesn’t decide how much the patient will owe; it simply reveals the pre-determined benefit.

As to the question posed, I don’t think co-pays are “lowered” but I do believe that pricing is intentionally obscured.  If I ask “how much does a bottle of twenty-four 2.5mg methotrexate tablets cost?” the right answer is never “It depends on your insurance.”  The right answer is, “That medication costs $___ if you’re paying cash.  If you have prescription coverage, part of that price will probably be covered by your insurance.”

Since the pharmacy needs my insurance information in order to tell me what the cash price would be if I didn’t have insurance, OF COURSE I suspect that they’re playing fast and loose with the numbers!  If pharmacies don’t want patients to think they’re fudging their numbers, they need to be transparent.

At Target, according to my mtx receipts:

  • 16 tabs:  $13.99 cash price
  • 24 tabs:  $20.49 cash price
  • 32 tabs:  $27.49 cash price

I pay less than that because insurance picks up part of the cost.  If I didn’t have insurance, I’d head to Costco:

  • 30 tabs:  $16.90
  • 50 tabs:  $23.36
  • 100 tabs:  $39.11

So, I’m curious… what does methotrexate actually cost?   What do other pharmacies charge?  I’m really curious if other people who use Target have a different retail value quoted on their receipts.  If you’re on mtx, please share your pharmacy and cash price (not what you pay after insurance) in the comments section.

5 thoughts on “At the Pharmacy

  1. I’ve wondered that too. I actually need more mtx and don’t have new insurance cards so will call and ask Target. That wouldn’t surprise me if they fudge the numbers.

  2. I’m a CPhT at a Publix Pharmacy (A prominent grocery/pharmacy chain in the southeast.) Without insurance, through our pharmacy it is $16.95 for 24 ct. I forgot to check other quantities, I will tomorrow. If you’re not aware, the cost per pill goes up with a lower quantity, even at the same pharmacy.

  3. I know this is an old post, but hopefully you’ll still see this. From what I understand, the insurance companies negotiate a lower price than the cash price. This is why they have to know your insurance info before they can tell you the price. So lets take one of your Target examples. You get the 32 tabs at $27.49. Your insurance negotiated that price and paid $17.49 while you paid your $10 copay, but a patient with no insurance probably pays $35 cash, meanwhile a different insurance (or same insurance but different policy) negotiated a price of $25 for that prescription and pays $10 while the patient pays his $15 copay. This is why some pharmacies refuse to accept some insurance policies, they can’t make a living at the negotiated rate, but a pharmacy or big box store can still make money, or make up the difference, because of the volume of prescriptions, or sales of other items in the store.

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