The high cost of prescription drugs is a serious problem for consumers. Health insurers either own or contract with pharmacy benefit managers (PBMs) to administer covered prescription drugs in their benefit plans. In addition to processing drug claims, PBMs also negotiate with both the drug manufacturers and the retail pharmacies to determine the cost of a particular drug to the plan sponsor and ultimately the consumer.
The pricing methodologies adopted by PBMs remain complex and opaque. Components include administration and clinical fees, retail markup, MAC lists, manufacturers rebates, and more. The end result is that the final cost of a drug can and does vary wildly; the same drug is never priced the same between insurance carriers. The adoption of high deductible health plans has brought this issue to the forefront. It is quite common for a member to see the cost for a drug change dramatically when their employer changes insurance carriers.
Enter prescription drug discount programs, which have become very popular with the advent of high deductible benefit plans. Programs offered by GoodRx, Clever RX, WellRx, and many others are routinely used by consumers to shop prescription drug prices. Their easy-to-use applications put the price of any prescription drug front and center for comparison purposes. Consumers often use these tools to compare what their own insurance plan is charging for a given drug.
Now that I have discovered that the cost of my drug is less with the discount card than it is with my insurance company, what are my options? If I use the discount card, will my insurance company credit my out-of-pocket expense towards my deductible? How does that work? Cornerstone surveyed our carrier partners to find out.
Cornerstone carrier partners Anthem, Aetna, Medical Mutual, Humana, and UnitedHealthcare will all allow members to use discount drug programs and file a paper claim to get deductible credit.
The amount that the member pays out-of-pocket can be applied if the prescription is a covered benefit and the dispensing pharmacy is in network. A paper claim must be submitted to the insurance company.
The drug in question must be covered on the members prescription drug list and all applicable clinical programs or plan provisions must be satisfied (PA, step therapy, and quality limits). Only the amount the member pays out-of-pocket will be applied to the deductible/out-of-pocket.
Prescription drugs can be expensive, but your clients have options. Cornerstone’s broker advisors are available to help you determine how best to serve your clients who are faced with the high costs of medications. Contact your representative today for more information.