I suppose this could go under 'Business' as much as 'Health and Fitness' but let's start here...

For the second time in a couple years, my dermatologist has prescribed a drug that has a 'list' price of >$3000 for a 30 day supply. For today's specific drug, it looks like my cost through my insurance would normally be ~$600/mo.

In both cases, there was some sort of 'co-pay card' or 'direct savings card' from the drug manufacturer available that knocks my cost down to $30/mo or even free. I don't know whether the difference is applied to my deductible or not.

What's going on here? My skeptical self says this is a way to get people 'hooked' on an expensive treatment option and the price will get jacked up later. On the other hand, I suppose this is no different than the 'free samples' doctors give out...it's just a larger sample and directly from the manufacturer. The timeline for when the 'co-pay card' will no longer pay is not defined (as far as I can tell).

If I needed this to stay alive, I'm guessing I'd look at $600/mo differently but this is more of a 'quality of life' improvement treatment that I likely will not be willing to pay more than ~$100/mo for. I can't imagine there are enough folks willing/able to shell out $600/mo for this treatment for the drug companies to make a profit but maybe I'm wrong.

Anyone have any insight into how long these 'direct savings' programs typically run and if the price drops once the program is over?

My doctor had absolutely no interest in discussing the costs of treatment with me (which is one of multiple reasons I'll be looking for a new doc).

I used one for my MS meds for many years. The game appears to be that the manufacturer just takes the cost of the "assistance program" and builds it into the drug cost that they charge the insurance companies. When I was on Rebif, the sticker price was $5400/month. The price they charged United Healthcare was actually something like $4500/month. United wanted me to pay $900/month for a copay. I contacted the manufacturer and they gave me a card that paid the copay for me.

After using that for a year or so, United sent out a notice that they were not going to let users use the copay cards from the manufacturer anymore (they owned the specialty pharmacy they forced us to fill the Rx through). The manufacturer turned around and said keep your receipt, send it to us, and we will repay you for whatever they charge you within 30 days (preferably 1 week). Eventually United realized that they were still going to get charged for the assistance, and were just making life more difficult for their customers so they backed down and let us keep using it.

So yeah, there is a likelihood that the insurance company will occasionally try to make it difficult to use, but don't expect the manufacturer to change things because they are just passing on the costs to the insurance company.

Worth a listen. Good info here.

Thanks! I'll take a listen on my drive home later. Any specific talking points for the co-pay cards?

Both of my prescriptions had to go through a specialty pharmacy as well which seems like another opportunity for grift. The doc (or his assistant) indicated it had to go through them because they are already set up with the co-pay cards as opposed to a random Walgreens/CVS/Walmart pharmacy. Both pharmacies have 'free' delivery too.

I guess I shouldn't be so skeptical but the whole process is setting off alarm bells with me asking, "Who is the sucker paying for all this?" I'll assume it's me until someone explains otherwise...I'm just not sure how.

dgb99 said:

---

Both of my prescriptions had to go through a specialty pharmacy as well which seems like another opportunity for grift. The doc (or his assistant) indicated it had to go through them because they are already set up with the co-pay cards as opposed to a random Walgreens/CVS/Walmart pharmacy. Both pharmacies have 'free' delivery too.

I guess I shouldn't be so skeptical but the whole process is setting off alarm bells with me asking, "Who is the sucker paying for all this?" I'll assume it's me until someone explains otherwise...I'm just not sure how.

---

It is mostly the insurance companies driving the "specialty pharmacy" racket. Each of them has their own setup and they force all "specialty" med Rxs to go there so they can get a cut of the profit back that would normally go to the retail pharmacy.

And right now, it is the insurance company that gets stuck paying for it...which means they just raise next year's premiums on everybody to pass the costs along. You pay for it eventually, but at a fraction of the cost you would pay eating the whole copay yourself.

My wife who worked for years in healthcare says a lot of this is for the pharma to build data for informatics.

My drive is ~25 minutes so I'm only about 20 minutes into the Youtube video but, so far, it seems like they are talking mostly about generic drug prices getting jacked up. Maybe my case is the same mechanism (pharmacy benefit managers as middlemen), but it feels different in this case.

Don't get me wrong…I absolutely believe the manufacturer of a new drug needs to be compensated for the research and release process that they have gone through. I'm just trying to understand how they are doing it in this case.

I suppose to expand the discussion, we could consider a few different situations:

1. Brand new drug - how do manufacturers get folks to use the new drug without long term efficacy data? Easy answer - give it away for free (or low cost) then jack up the price. Is this what happens?

2. Older drug still under exclusivity/patent - Is this where the price jumps? How do insurance companies handle this jump (if it happens)?

3. Generic drugs - I'll be honest that I don't know much about this situation. My uneducated view is that if there really are middlemen jacking up the price of generic drugs, those companies should be eviscerated and their executives forced into high-level government positions for <$200k/year salary. Maybe they could put their talents to better use making government more efficient.

*** Note: patents for my specific drug that started this thread expire in 2037 based on limited research.

I'm guessing the price was always going to be whatever they charge the insurance company but they have to do crap like this to satisfy the co-pay portion of your insurance policy. Kind of reminds me of the days when all the big ticket products at Best Buy came with a mail in rebate. Of course it also reminds me of roofing companies waiving the deductible which I think is illegal in Texas. I really don't think there's much risk the manufacturer jacks up their overall price. I think the risk is the insurance industry figures out a way to force the consumer to pay the copay. I could see them lobbying state legislatures to ban the practice of reducing or waiving copays.

The manufacturer discount cards are billed as a secondary "insurance" for those that are insured. Most have a maximum monthly or annual coverage amount for what they're willing to pay towards your copay. It's primarily a rebate of sort similar to what they offer government insurance plans.

I was prescribed Mounjaro in October 2023. The list price per month is $1,050. With my insurance I only had a $75 copay. I found a manufacturer's coupon and it only cost me $25 per month but it expired on December 31, 2023.
These coupons are valid for 3 months but CVS doesn't often have my coupon in their system, so I just reapply online and in 24 seconds I have an image on my phone that gives them the numbers they need to use the coupon. So in 2024 I look and the program is still available with a December 31, 2024 deadline. After using my January coupon CVS tried to charge me $75 in February. I spent another 24 seconds and got a new card and showed that and it was $25. Apparently the drug manufacturer doesn't keep up with my identity as far as I know.
The medication is for diabetes type 2 and I went from 195 to 175 on my own in 5 months then took the Mounjaro since August 2023 and they titrate it up by 2.5 mg every 4 weeks. I'm on 10mg once a week.
Good news and bad news.
The good news is OMG I went down to 144 pounds with much better glucose numbers. My blood pressure was normal for the first time in 20 years because of the weight loss.
The bad news. I lost my appetite almost completely. Junk food like pizza looked like a pile of cow poop. Disgusting. I only liked ice cream and chicken pot pies. The pot pies became disgusting in time but I'm good with ice cream. My face aged and got wrinkles. I aged 5 years in 5 months. I used to be obsessed with power lifting and I think I am 35% as strong now.
So at 144 pounds I stopped the meds until I reached 150. At 152 I started back but food was appealing for a week. Unless you experience it one can hardly imagine 99% of food becoming undesirable. I plan to up my protein soon and begin lifting ( it will be humbling) again. Sorry I drifted into another topic.
I don't think the savings from the coupon will affect your deductible. I'd use the coupon and see if you like the new meds. Maybe when the coupon expires you can quickly get another.

Use goodrx.com next time you need to buy prescription meds. It's completely free to use the website, just need to match the right prescription to the pharmacy chain you're picking up from. It doesn't work for all prescription meds, but it worked the last time I needed to buy an epipen and some antibiotic ear drops for an ear infection.

Would have cost >$600 together with my insurance for those. With goodrx, cost me something like $180. Pharma is a racket

Thanks for all the feedback. Here's the final tally for this particular drug:

Zoryve 60g - this will likely last me longer than however long it is supposed to last
List price (I think) $1025
My insurance knocked it down to $663.
The specialty pharmacy and/or savings card knocked it down to $75 truly out of pocket

Looking at my insurance website (Caremark), I could have gotten it from a different specialty pharmacy for $617. But no details are available from the original pharmacy as far as how/why my cost was $75 so my end cost might have been the same. I will likely shop around and/or get more info about the savings card if/when I have to refill...

I did check goodrx and the lowest price they show is $851. I also recommend checking goodrx as I have found multiple drugs cheaper than through my insurance including Tamiflu a few years back.

Struggling with the prescription drug boondoggle

Drug in January for 180 qty is $111
Same drug and quantity today is now $283

Prescription plan said the manufacturing cost is the same ($1500), but the prescription plan negotiated rate (or contract rate) has changed, resulting in a higher patient responsibility. I'm wondering if CVS maybe used a discount card in January and now that card doesn't exist so I'm getting hit with the full copay (maybe)?

This whole thing seems like lack of transparency / black magic crap. Tell me if this flanges up with others who have knowledge. Possible for the same drug to fluctuate in price like this month to month. On top of things, this is generic so seems absurd to me. Maybe I should go yell at some clouds.

SnowboardAg said:

---

This whole thing seems like lack of transparency / black magic crap. Tell me if this flanges up with others who have knowledge. Possible for the same drug to fluctuate in price like this month to month. On top of things, this is generic so seems absurd to me. Maybe I should go yell at some clouds.

---

Anything is possible because there is no price transparency in healthcare. Insurance, hospital corporations, and big drug companies own congress. They have so many protections to allow them to do almost whatever they want.

However, none of us have any power to change it. Best I can offer you is to check out a company like Mark Cuban's CostPlus Drugs. Or try and find your drugs from a Canadian or European pharamacy. Even an Indian pharmacy.

https://costplusdrugs.com/medications/