What’s up with the Pharmacy claiming I paid much more than I actually did

Prescription Drug Benefits Forum
1

This is the second time I’ve seen this issue pop up over the last few years. It happened with two different insurance companies. I recently got some acne creams from local compounding pharmacies that were prescribed to me. The retail price for these is usually around $500, but the compounding pharmacy only charges me $50.
What’s puzzling is that my insurance thinks I’m paying $500. The first time this occurred, I just got a check in the mail because my insurance said I had paid way more than the deductible, so they reimbursed me 80% of that amount.
Now, it’s happening again with a different pharmacy and a new insurance company. I’ve paid about $200, but they say my deductible is almost met, which is $2000. I suspect this has something to do with PBMs and rebates, but I really want to know what’s going on here and the ethical side of it all.

3

The pharmacist might be using a manufacturer’s discount coupon without telling you, and your plan doesn’t exclude support from third parties or have an accumulator.

4

This can occur if there’s a manufacturer coupon involved. The insurance processes the claim, shows you a $500 cost-share, and then the coupon covers the remaining $450, which leaves you just paying $50.

But from the insurance’s viewpoint, you’ve “paid” the complete $500 toward your deductible.

I also manage to avoid my $2.5k deductible for one of my prescriptions this way.

5

@Vail
I’ve experienced this too. My family deductible is $4k, and one of my medications costs $3800 each month. The manufacturer’s copay assistance covers that month. By the time I add in my other medications, I reach my family deductible in January. I also have a $4k individual max OOP that I meet that way, so my cost share becomes $0 for the rest of the year. I suggest always signing up for copay assistance cards for any medication that provides them.

6

Isn’t Walgreens in a class action lawsuit over this? I didn’t read everything too closely, but it sounds similar to what they were doing. It ended up being cheaper to fill some prescriptions without using insurance.