Why a patient paid a $285 copay for a $40 drug


The copay for a 90-day supply was $285, which seemed high to Ma.

“I couldn’t understand it — it’s a generic,” said Ma. “But it was a serious situation, so I just got it.”

A month later, Ma and his wife were about to leave on another trip, and Ma needed to stock up on her medication. Because 90 days hadn’t yet passed, Anthem wouldn’t cover it. So during a trip to his local Costco, Ma asked the pharmacist how much it would cost if he got the prescription there and paid out of pocket.

The pharmacist told him it would cost about $40.


So the solution is more deregulation, right? Or we have to overpay 7x so drug companies can save the world on our expense? Or do we need to wait for every obese American to trim down before we can do anything?


Costco is great for generic prescriptions. Did that for my parents years back when they were visiting and didn’t have insurance coverage. The pharmacists there (have some friends who are pharmacists there) also have much higher job satisfaction that at CVS, Walgreens and the like


Very few people comparison shop. It’s amazing how much drug prices can vary.


Drug prices should not be allowed to vary by 7x. In this case I don’t think it’s even the pharma company charging more. It’s the insurance company screwing the patient.

We should not allow that.


I agree. Pricing is crazy complex. It involves the pharma company, the benefit management company, the insurance company, and the retailer. What’s probably happening is the insurer gets the rebate if you use is insurance. If you buy it, then you get the rebate. The price is the same and the difference is who pockets the rebate.


We need competition. Pharmacy needs a lot more competition. We should deregulate, yeah, deregulate to allow Walmart, Costco and Amazon to effectively compete in both genetic and prescription drugs.

Too much regulations are protecting the PBMs from too much artificial barriers. Make the medicine easy to buy, from anywhere. Even not require a pharmacist to be onsite to sell drugs. Also make the lawsuit go away.

Top 3 PBMs controls 78% of the market. Competition does not exist for a particular patient or consumer.

“ As of 2016, PBMs managed pharmacy benefits for 266 million Americans.[2] PBM´s operate inside of integrated healthcare systems (e.g., Kaiser or VA), as part of retail pharmacies (e.g., CVS Pharmacy or Rite-Aid), and as part of insurance companies (e.g., UnitedHealth Group).[1][6] In 2016 there were fewer than 30 major PBM companies in this category in the US,[1] and three major PBMs (Express Scripts, CVS Health, and OptumRx of UnitedHealth Group) comprise 78% of the market and cover 180 million enrollees.[1][7]


It is the drug store that is responsible for this. If you go to CVS this won’t happen.


I joined the gold membership also.
one drawback is it doesn’t count toward deductible.

drug price are ridiculous. my experience
1)generic drug i used if go thru insurance will cost around 250. if i buy the same generic brand from same place maybe like 10-20 bucks cheaper. if used goodrx gold memebership i only pay 81
2) i can get another generic brand online from canada i think for 50

Each generic brand cost different, so pretty hard to compare, i went with goodrx thru CVS because i trust what i’m getting.


That old couple used MediCare insurance and the pricing through Medicare claims is still much higher than uninsured price.

We need to deregulate drugstore and make it more competitive.

I like to see as many places selling medicine as selling bread.

Currently consumers lack the influence on pricing. If consumers know the price and can shop around, this pricing inefficiency will disappear.

Deregulate and make it simple. Remove all the complexity and make the price public and easy to search.

Now I remember that one time the pharmacy guy told me to pay on my own since I would need to pay a lot more if go through insurance. Did he make the pharmacy profit less by giving me good advice?


I don’t think pharmacies have big margins. If they made a ton of money off the prescription drugs, then they wouldn’t carry all the other stuff in the store. They’d just have a much smaller store with far lower overhead. CVS has as 5.4% net profit margin.

Express scripts has a 5.5% net margin. I’m actually surprised it’s so low.

Pfizer has a 29% net margin, and that’s after spending 28% of revenue on sales and marketing. No other developed country allows drug companies to directly market to consumers which leads to much higher sales. The US consumes 80% of the prescription drugs in the world.


Prescription drug is prescribed by doctors. Is there a collision between doctors and pharmaceuticals?

Is insurance company neutral on drug pricing? Is there any conflict of interest between insurance company and self-insured employers?


Here is a good article about physicians receiving money from drug companies.

There are a lot of anecdotes I can give you about pharma payments to doctors and hospitals but suffice it to say they usually stay within legal boundaries. It is illegal to give them kickbacks for prescribing their products but there’s legal ways to get around it. Read the article I referenced.


I had a friend in Michigan that was a pharma rep and another friend that was an ER resident. The pharma rep got in trouble if he didn’t spend enough on his expense account. If it was looking light, then it was time to go play some golf and get bottle service at the club.


Yet another example how the system is broken. You have a 6 figure hospital bill even if you are insured.


Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor that does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out-of-network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.

Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.

But there’s a huge loophole: Those state-mandated protections don’t apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds. Federal law governs those health plans — and it does not include such protections.

Most big tech companies self insure. Make sure to read the fine prints on your plan.


Who self-insures? I don’t think any big tech company does. They all buy employees plans through third parties.


I have a vague recollection that google does, but uses anthem for administration.


Intel self insured when I was there. Most big companies do because their employees tend to be younger and male.


Why don’t you just think and talk about universal healthcare like in advanced countries, not this third world country with a banana dictator.