Copays and different pharmacies

[ZakMeister]

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This may be a basic question to most, but I would appreciate if anyone can answer it.

Copays (not coinsurance) are set fees determined by the third party payer for either generic or brand of any formulary drug. So how does this makes patients decide which pharmacies to go to as the copays may be the same regardless? Am I looking at it correctly?

 

[romaniangirl]

From what I've heard from various patients, they choose the most convenient pharmacy for them. Some people prefer big names like walgreens and CVS that are like mainly drug stores while others prefer grocery stores where they can shop while their rx is being filled. Others choose it based on location or wait times, or even whether a particular store carries their meds (usually for weird brand names).

 

[TonyRx]

A patient's copay will be based upon their set formulary as well as if they are getting their prescription filled at a Preferred or Non-preferred pharmacy. Walgreens, CVS, etc, etc, all sign contracts with these major insurance/pbm's and either gain Preferred or Non-preferred status. This is why you'll get the occasional patient who complains that their copay was higher/lower at one retailer versus another for the same drug/quantity.

 

[BidingMyTime]

Question, when did this change with Medicare Part D patients? When Medicare Part D first came out, wasn't that a requirement that the person's copays/discounted rate while in the donut hole had to be the same across all participating pharmacies? But now, pharmacies apparently can have preferred/non-preferred status with Medicare Part D? I'm not sure if I'm misunderstanding something, or if it actually did change at some point.

 

[PharFromNormal]

Preferred pharmacies are able to charge the patient a lower copay because they have agreed to terms that include a lower reimbursement from the third party. By accepting lower reimbursement rates the third party is driving volume to the pharmacy as it is a well known concept that cost is a major factor in where people purchase things.

In addition, outside of medicare, you can have limited or restricted networks where by agreeing to less favorable terms, a third party will only reimburse or "cover" a patient's prescriptions if they are filled at that specific pharmacy.

It's a rapidly growing managed care trend that in theory rewards those accepting of terms that save a third party prescription cost, with volume or share of their covered lives.