Author Topic: ACA General and Prescription Question  (Read 1505 times)

ltt

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ACA General and Prescription Question
« on: August 26, 2021, 11:58:07 AM »
Am hoping someone can answer a few questions for me.

We have an ACA gold plan.  From what I'm reading, the ACA plans (not Medicaid or a children's plan) are private health insurance programs.  Is that correct?

I picked up a prescription the other day.  Pharmacist applied a manufacturer coupon which substantially lowered the price of the prescription amount I was expecting to pay.  Do I need to let the insurance company know of the coupon which was applied? 

I am confused about how this all works.  Thanks for your help.

plog

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Re: ACA General and Prescription Question
« Reply #1 on: August 26, 2021, 12:20:35 PM »
Yes ACA is private health insurance.

No, you don't need to let them know about coupons.  I've heard really good things about GoodRX--multiple stories where if they used their coupon its actually a better deal than going through insurance.  No idea how that works, but does anyone really know how the finances of medicine works in the US?

jim555

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Re: ACA General and Prescription Question
« Reply #2 on: August 26, 2021, 12:43:55 PM »
Your plan will state what the drugs cost, for example generics are $3, brand name $15.  GoodRx may be cheaper than the plan in some cases.

ltt

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Re: ACA General and Prescription Question
« Reply #3 on: August 26, 2021, 01:11:27 PM »
Your plan will state what the drugs cost, for example generics are $3, brand name $15.  GoodRx may be cheaper than the plan in some cases.

My expected cost, after insurance, was over $200 which went toward deductible on our ACA plan.  The manufacturers coupon at the pharmacy lowered it to under $100.  That's why I was wondering if I need to call the insurance company--how does it all work? 

jim555

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Re: ACA General and Prescription Question
« Reply #4 on: August 26, 2021, 01:35:49 PM »
Your plan will state what the drugs cost, for example generics are $3, brand name $15.  GoodRx may be cheaper than the plan in some cases.

My expected cost, after insurance, was over $200 which went toward deductible on our ACA plan.  The manufacturers coupon at the pharmacy lowered it to under $100.  That's why I was wondering if I need to call the insurance company--how does it all work?
I would call them.  Maybe the drug wasn't in the plan list of covered drugs.  Your plan documents should have the info.

Paul der Krake

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Re: ACA General and Prescription Question
« Reply #5 on: August 26, 2021, 01:49:04 PM »
To understand what's going on here you need to understand drug formularies and pharmacy benefits managers (PBMs).

A PBM is an organization whose job is to negotiate prices for their clients, creating a catalog of drugs. Their client is usually not you, it's the insurance carrier. You may have seen their names on your plan's card or paperwork. The big ones are ExpressScripts, Caremark, Optum. To make things even more complicated, they are often owned by insurance companies, but tend to operate as their own divisions.

So the normal flow is:
1. PBM develops drug formulary by negotiating with drug manufacturers, pharmacy distribution networks
2. Insurance company hires PBM
3. Insurance company and PBM develop plan benefits, saying plan members will pay, for example, $10 for prescription drugs
4. Pharmacies, PBM, and insurance plan determine who gets how much for every prescription filled
5. Consumer shows up at pharmacy, shows insurance card, drug formulary and prices pull up on the pharmacist's screen, consumer pays price that's been agreed upon by everyone involved so far

Enter GoodRX and similar coupon apps. They realized that the way many insurance plans are structured can be a very bad deal for consumers. Maybe a drug isn't covered by the drug formulary at all, or maybe it's covered at too high a price.Recall that pharmacies, manufacturers, PBMs, and insurance companies all split the proceeds.

GoodRX, on the other hand is essentially a standalone PBM that markets directly to consumers, cutting out the insurance company. When you use their coupons, it's their pre-approved pricing that kicks in, not the insurance company.

Note that none of this has anything to do with the ACA. This is how pharmacy benefits work for everybody, not just ACA plan members.

yachi

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Re: ACA General and Prescription Question
« Reply #6 on: August 26, 2021, 02:19:35 PM »
Yes ACA is private health insurance.

No, you don't need to let them know about coupons.  I've heard really good things about GoodRX--multiple stories where if they used their coupon its actually a better deal than going through insurance.  No idea how that works, but does anyone really know how the finances of medicine works in the US?

I figured out how this works in the US, at least as it applies to prescriptions.  It turns out that the finances of medicine generally follows an acronym: BOHICA.

There's simply no other explanation why a medicine that costs $50, shipped from the other side of the world without insurance, should cost $270 at my local pharmacy.

stoaX

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Re: ACA General and Prescription Question
« Reply #7 on: August 27, 2021, 04:35:50 AM »
To understand what's going on here you need to understand drug formularies and pharmacy benefits managers (PBMs).

A PBM is an organization whose job is to negotiate prices for their clients, creating a catalog of drugs. Their client is usually not you, it's the insurance carrier. You may have seen their names on your plan's card or paperwork. The big ones are ExpressScripts, Caremark, Optum. To make things even more complicated, they are often owned by insurance companies, but tend to operate as their own divisions.

So the normal flow is:
1. PBM develops drug formulary by negotiating with drug manufacturers, pharmacy distribution networks
2. Insurance company hires PBM
3. Insurance company and PBM develop plan benefits, saying plan members will pay, for example, $10 for prescription drugs
4. Pharmacies, PBM, and insurance plan determine who gets how much for every prescription filled
5. Consumer shows up at pharmacy, shows insurance card, drug formulary and prices pull up on the pharmacist's screen, consumer pays price that's been agreed upon by everyone involved so far

Enter GoodRX and similar coupon apps. They realized that the way many insurance plans are structured can be a very bad deal for consumers. Maybe a drug isn't covered by the drug formulary at all, or maybe it's covered at too high a price.Recall that pharmacies, manufacturers, PBMs, and insurance companies all split the proceeds.

GoodRX, on the other hand is essentially a standalone PBM that markets directly to consumers, cutting out the insurance company. When you use their coupons, it's their pre-approved pricing that kicks in, not the insurance company.

Note that none of this has anything to do with the ACA. This is how pharmacy benefits work for everybody, not just ACA plan members.

That's the best explanation I've read of how Rx coverage works in the US health insurance market. 

I say that as a retired healthcare underwriter.

Fishindude

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Re: ACA General and Prescription Question
« Reply #8 on: August 27, 2021, 07:06:16 AM »
Yes ACA is private health insurance.

No, you don't need to let them know about coupons.  I've heard really good things about GoodRX--multiple stories where if they used their coupon its actually a better deal than going through insurance.  No idea how that works, but does anyone really know how the finances of medicine works in the US?

Exactly how I would have answered, and I'm an ACA customer.

hooplady

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Re: ACA General and Prescription Question
« Reply #9 on: December 07, 2021, 05:26:55 PM »
Chiming in to say, although I'm not on ACA (yet) I'm on my former employer's insurance as a retiree and just discovered that GoodRx and other sources can save me a lot on my prescriptions. What's really crappy is that GoodRx shows a much lower price for some of my scrips at the pharmacy I already use (CVS) as part of my insurance plan! This is supposedly a "consumer-driven" healthcare plan, but they still don't make it easy to be a wise consumer when it comes to medical costs. Learned my lesson, I'll be getting paper Rx from all of my docs from now on and shopping around for the best prices available.

Oh, and GoodRx and others cover pet meds as well!

chasesfish

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Re: ACA General and Prescription Question
« Reply #10 on: December 08, 2021, 06:16:14 AM »
Your plan will state what the drugs cost, for example generics are $3, brand name $15.  GoodRx may be cheaper than the plan in some cases.

My expected cost, after insurance, was over $200 which went toward deductible on our ACA plan.  The manufacturers coupon at the pharmacy lowered it to under $100.  That's why I was wondering if I need to call the insurance company--how does it all work?

My experience is this is an either/or decision with an ACA plan.   You can either take the contract price and have it added towards your deductible, or you can buy it with a coupon outside of your healh insurance contract and it does not apply to your deductible.

Our experience with our ACA plan thus far is they will fight to disallow as much as they can to count towards the deductible.