This is very, very niche, but I couldn’t think of a more suitable place so I’ll give it a go.
In the US, brand name medications are outrageously priced. There are deals between payors (PBM/Medicare) and manufacturers that look like this:
Sticker price $20,000/mo minus negotiated insurance payment of $15,000 theoretically leaves pt on the hook for $5.000/mo, BUT…
Manufacturer graciously offers a “coupon” / discount card, which covers a max of $4,995.00, leaving pt with a net responsibility of $5.00/month.
These are convenient numbers to work with, but closely resemble the pricing and coverage structure of a long-term medication I take.
The coupon never results in zero pt responsibility, always leaving some negligible amount due. Invariably, it’s exactly enough money to be a huge pain in everyone’s ass and to make no meaningful difference to anyone involved in the transaction. $5.00 and $9.00 are amounts I see frequently.
Getting to the actual question, why bother?
Seriously, I wasted a half hour of my life waiting on hold to schedule a refill on a specialty med that can only be filled from a single central pharmacy and shipped, to be told that a) they somehow didn’t charge card on file for the $5.00 last month, and b) can’t schedule next shipment until I pay the all-important five bucks. Didn’t have a card close at hand, had to call back later so they could extract their couple dollars and then schedule the next round.
It literally costs them more in toll free charges, infrastructure fixed costs, and salaries to collect that money than they make from it.
I assume the answer is something along the lines of “personal responsibility” and someone in Congress having a stroke over the idea of someone getting medicine for “free,” but I’ve been unable to substantiate that.
Convinced there is a reason, probably buried in a 10,000 page CMS policy manual, because the mfg coupon literally never brings the price to zero. See, e.g., DTC drug commercials referencing “pay as little as $x a month!”
I just had the odd experience of using a manufacturer’s discount card to pick up a medication for my wife. The medication is relatively expensive and seldom covered by insurance.
According to the information on the card, if you have private insurance which covers the medication, the discount card covers the co-pay, so you pay nothing. However, if your insurance doesn’t cover the medication, the discount card covers the cost, and you still pay nothing.
Our insurance didn’t cover the cost, and we didn’t pay anything for the medication.
I don’t understand how that works.
My dog is on Clonidine and the vet doesn’t carry it so I’m getting that filled at Costco. I can’t remember how it they said it was but they “used a coupon” to get it down to $10. Why isn’t that just the regular price if its basically transparent to me? I suspect the answer there is some benefit, probably when dealing with medicaire, to having a higher price listed on the drug schedule.
Get as much out of the insurance as possible
I’m mildly curious to see what happens in the next month or two, as I’m about to hit my OOP max. Never ran into that combo of scenarios before.
The one I’m thinking of has a couple months “bridge” program for uninsured/just started new job/etc, but very time limited and an even bigger hassle as they’ll only send out two weeks instead of a month supply with each shipment.
IIRC, if I had insurance and it explicitly excluded the drug, the card would cover it, but it’s been a couple years since I left that job so memory isn’t clear.