I had my doctor write me a 1-year, single fill prescription for a generic med I take.
I filled it at the local Safeway with a GoodRx coupon for $346.
Clerk at the pharmacy asks if I want to use my Aetna Medicare Part D insurance. So I ask, “What do they charge for a 90-day fill?” (i.e., the most Aetna will authorize.)
Answer, “$260”.
Tell me again what service my $20 million/year health insurance CEO is providing me.
intercst
Tell me again what service my $20 million/year health insurance CEO is providing me.
At a minimum, they’re providing the same service (generally) that GoodRx is providing you - negotiating huge discounts off of the ‘cash’ price for drugs in exchange for a fee. GoodRx basically makes a boatload of money by exploiting the broken pharmacy pricing system, the same way that other PBM’s do:
https://www.drugchannels.net/2020/08/how-goodrx-profits-from…
They take a 15% skim off of their pharmacy payments. Because different PBM’s have different prices for different drugs, sometimes an insurance patient can further arbitrage between GoodRx and their provider - but that just shifts costs to elsewhere in the system. GoodRx isn’t providing any value at all other than exploiting some of that arbitrage.
Albaby
albaby1 writes,
They take a 15% skim off of their pharmacy payments. Because different PBM’s have different prices for different drugs, sometimes an insurance patient can further arbitrage between GoodRx and their provider - but that just shifts costs to elsewhere in the system. GoodRx isn’t providing any value at all other than exploiting some of that arbitrage.
That’s nonsense.
Aetna owns CVS (their captive Pharmacy Benefit Manager) So Aetna/CVS is getting the 15% insurance skim, plus whatever they can roger from their mostly uninformed customers on the PBM side.
Aetna/CVS has far larger book of business than GoodRX and should be able negotiate more favorable pricing if Aetna was actually being managed for the benefit of the customer.
The fact that they’re charging three times the GoodRX price for the same generic medication is just flat out price gouging.
intercst
Aetna/CVS has far larger book of business than GoodRX and should be able negotiate more favorable pricing if Aetna was actually being managed for the benefit of the customer.
No, they don’t. GoodRx partners with more than a dozen different PBMs, and one of them is Express Scripts - the largest PBM in the country at 83 million, which is more than double the size of Aetna (about 39 million for all services). Add in all the other PBMs, like OptumRx (66 million subscribers), Medimpact (55 million) and Navitus (Costco’s PBM, couldn’t find the sub numbers), and GoodRx has access to a PBM base that’s an order of magnitude larger than Aetna alone.
GoodRx gives you access to an arbitrage between all those PBMs (which again, are each larger than Aetna) for each individual drug. The PBMs will negotiate different discounts for different drugs, and they can be different across different PBMs. So if Aetna is cheaper than other PBM’s for some drugs and more expensive for others, GoodRx can ‘borrow’ the rate for the cheaper PBM for that specific drug.
Albaby
albaby writes,
<<Aetna/CVS has far larger book of business than GoodRX and should be able negotiate more favorable pricing if Aetna was actually being managed for the benefit of the customer.>>
No, they don’t. GoodRx partners with more than a dozen different PBMs, and one of them is Express Scripts - the largest PBM in the country at 83 million, which is more than double the size of Aetna (about 39 million for all services).
Aetna CVS/Caremark fills 32% of the prescriptions in country, GoodRX less than 1%. (Express Scripts, owned by Cigna. has only a 24% market share.) I think you need better information.
https://www.drugchannels.net/2021/04/the-top-pharmacy-benefi…
Don’t buy the nonsense that Aetna incapable of providing their customers preferred pricing like GoodRX.
intercst
Aetna CVS/Caremark fills 32% of the prescriptions in country, GoodRX less than 1%. (Express Scripts, owned by Cigna. has only a 24% market share.) I think you need better information.
I’m not sure your link says anything all that different than my information. GoodRx’s PBM partners (Express Scripts, OptumRx, and MedImpact) collectively have about 51% of the prescription market, compared to the 32% that CVS Caremark (Aetna’s PBM partner) fills. I agree that I used Aetna’s actual subs rather than the combined Aetna CVS Caremark numbers (and Caremark has 75 million subscribers, which combined with Aetna does make them the largest) - but GoodRx has them beat in terms of the book of business that their combined PBM’s bring to the table. CVS is #1, but GoodRx has partnered with #2, #3, and #5 - which enables their users to pick and choose between the rates that each of those PBM’s has negotiated for the various different drugs they cover.
Albaby
albaby writes,
GoodRx has them beat in terms of the book of business that their combined PBM’s bring to the table. CVS is #1, but GoodRx has partnered with #2, #3, and #5 - which enables their users to pick and choose between the rates that each of those PBM’s has negotiated for the various different drugs they cover.
That’s immaterial.
Aetna/CVSCaremark has their own employee pharmacists overseeing high-volume robot pill bottle filling machines. Aetna negotiates directly with Indian generic drug manufacturers to get the best, high volume pricing. I don’t have any doubt that this part of Aetna’s business is being run as cost efficiently as possible.
I’ll concede the point that Aetna may not have the best price in each and every pharmacy where you may present your insurance card.
But for Aetna’s mail order pharmacy, they control the whole, vertically-integrated operation from buying the drug in India to putting the pill bottles in the envelope for US Postal delivery to the patient/customer. They are not at the mercy of what other PBMs are doing. The largest PBM, direct to customer, mail order pharmacy should be offering the best pricing, if it’s being run honestly.
This was actually how PBMs operated when the industry was born in the late 1960’s. But by the late 1980’s they’d been fully corrupted and started to focus on Executive Compensation rather than delivering the best discount to the consumer.
intercst
As noted here before, Part C and Part D were designed to, primarily, benefit the insurance industry.
When I got my Shingrix shots, my Part D would have covered them, but not saved me a nickle, because I have nothing else to apply to the deductible. Good Rx was cheaper than using the insurance I pay for.
Steve
When I got my Shingrix shots, my Part D would have covered them, but not saved me a nickle, because I have nothing else to apply to the deductible. Good Rx was cheaper than using the insurance I pay for.
I was lucky that I got the Shingrix vaccine while I was still on “free Obamacare” (vaccines are considered “preventative health care” with no deductibles or co-pays under Obamacare, but oddly not under Medicare.)
That may be changing. The current, last ditch effort for the Administration to provide something to the voters before November includes a $2,000/yr maximum out-of-pocket cap on Medicare Part D, as well as free vaccinations.
intercst
I’ll concede the point that Aetna may not have the best price in each and every pharmacy where you may present your insurance card.
But for Aetna’s mail order pharmacy, they control the whole, vertically-integrated operation from buying the drug in India to putting the pill bottles in the envelope for US Postal delivery to the patient/customer. They are not at the mercy of what other PBMs are doing. The largest PBM, direct to customer, mail order pharmacy should be offering the best pricing, if it’s being run honestly.
That may be the case, but from your original post, you weren’t “at the counter” of the direct to customer mail order pharmacy. You were at the counter your local Safeway. There is enormous variability in the reimbursement rate from any single PBM to different pharmacies, even for generics; and of course there’s enormous variability in what any given pharmacy negotiates among the different PBMs, and indeed different discounts off of usual and customary pricing for different drugs in the formulary. It’s not a perfect analogy, but you’re comparing the “out of network” price for that drug at that pharmacy to the “in network” price of a PBM that Safeway is offering steeper discounts to in order to get customer flow to their pharmacy. I suspect (though I don’t know for sure) you’d get a much better price from Aetna if you were at a CVS.
The GoodRx coupon is just a user interface to match you to the best PBM for that specific pharmacy for that specific drug, so the pharmacy can get some better order flow and get a customer into the store. If something is free, then you’re the product - and it’s not surprising that Safeway would be willing to negotiated a steep discount on at least some drugs in order to get bodies through the door. And GoodRx makes some money off the ads they show you as well.
Albaby
albaby writes,
That may be the case, but from your original post, you weren’t “at the counter” of the direct to customer mail order pharmacy. You were at the counter your local Safeway. There is enormous variability in the reimbursement rate from any single PBM to different pharmacies, even for generics; and of course there’s enormous variability in what any given pharmacy negotiates among the different PBMs, and indeed different discounts off of usual and customary pricing for different drugs in the formulary. It’s not a perfect analogy, but you’re comparing the “out of network” price for that drug at that pharmacy to the “in network” price of a PBM that Safeway is offering steeper discounts to in order to get customer flow to their pharmacy. I suspect (though I don’t know for sure) you’d get a much better price from Aetna if you were at a CVS.
Nope. I checked the Aetna/CVSCaremark mail order price for four 90-day fills and it was about the same as the in-store Safeway Pharmacy price. Aetna’s captive PBM customers are not getting any cost benefit from volume purchasing on the mail order side. It’s all going to Executive Compensation.
There isn’t any way you can defend this behavior.
intercst
Consider costplusdrugs.com as an alternative if you can wait a few days for your prescription to arrive in the mail. Full name of the company is Mark Cuban Cost Plus Drug Company. I’ve looked to refill a prescription recently and found the prices about 25% lower than my private insurance, even after shipping. Your mileage may vary depending on the prescriptions you have.
j
I suspect (though I don’t know for sure) you’d get a much better price from Aetna if you were at a CVS.
Nope. I checked the Aetna/CVSCaremark mail order price for four 90-day fills and it was about the same as the in-store Safeway Pharmacy price.
Then what do you mean, “nope”? When you asked for a price for the drug “out of network” at Safeway, they quoted you $260 for a 90-day supply - or $1,040 for the full year. But when you went to Aetna mail order - the “in-network” price - they quoted you roughly $260 for the full year. That’s a vastly better price from Aetna using their provider - which is what I suspected.
There isn’t any way you can defend this behavior.
What are you talking about? Aetna’s giving you what appears to be the rock-bottom price on your scrip - including delivery straight to your door. The only way that GoodRx can even match it is by selling you as the product - first to their advertisers, and then to Safeway. It’s not surprising that Safeway might be willing to offer a discount (and maybe even to take a loss) to force you to come into their store; but even then, they couldn’t beat Aetna’s price which would give you (again) home delivery without having to go to a store.
There’s lots of depredations in the insurance market, but your anecdote doesn’t support the claim that Aetna’s doing you wrong. They offered you the best available price for your scrip - as good as the best available of the other large PBM’s - with the convenience of home delivery and without having to be ‘sold’ to marketers and another chain. Considering that GoodRx’s PBM partners are collectively larger than Aetna/CVS/Caremark, I’d say that there’s nothing that needs defending.
Albaby
But when you went to Aetna mail order - the “in-network” price - they quoted you roughly $260 for the full year. That’s a vastly better price from Aetna using their provider - which is what I suspected.
OCD: s/b $343 for the full year. Still vastly better than what you would have gotten using Aetna at the Safeway, which would have been $1,040. Which was my point - the big gap in prices was the result of the mismatch between PBM and pharmacy, the “out-of-network” issue.
Albaby
That we even have these discussions about the least bad deals for pharma in USA is proof of the insane disgrace of USA healthabuse system.
The staggering cost of my Blue Shield medicsl insurance over years, time wasted wrestling with forms and rules and stupidities and waiting on hold on phone, and stress I had to put up with as a cost of living with the USA healthcare industry was staggering, and is one of the reasons I so prefer life as a permanent resident abroad, even when paying “full cost with no insurance” in Mexico, where my HIV is expertly treated with high quality drugs absolutely for free, and endoscopies and cataract surgery and dental care all cost less than my USA deductibles…
CRAZY! Demanding Revolution!
And hmmmm, thinking on this subject I suddenly realized that about one third of my very gifted and high value educated (overwhelming tech) nieces nephews and godchildren godgrandchilren have chosen to bail on the USA and also live abroad. A macro indicator of some importance.
david fb
That we even have these discussions about the least bad deals for pharma in USA is proof of the insane disgrace of USA healthabuse system.
Yes, yes, and also yes.
Reading this debate between intercst and albaby about which private company has ‘the least bad deal’ has been amusing and sad at the same time. I would give albaby the edge on logic (as always), but intercst wins for me overall with his sense of passion and indignation, which I see as necessary to get any movement on improvement.
Pete
Raised by an Irish trained doctor I got a front row seat for some 45 years on the daily bull on this topic. He has fought and fought for the American public. The public just now is beginning to get it en mass.
Up in Kennebunk end of June with an Irish cousin and his wife out of Waterford, she is a radiologist. I asked her about medical school costs. She told me university for anyone and medicine is $3000 per year. Making that Euro…similar obviously in the exchange rate. Medical school is five years as an undergrad in Ireland. Another cousin’s daughter recently graduated med school in Dublin. She had done a science degree undergrad making her years in med school post grad work. She was paying $15000 per year. She borrowed less than $75k.
Asked the radiologist about pay in Ireland v the US for doctors, she had practiced at Yale and Duke some 25 years ago, she said pay was on a par Irish v US for doctors. I am not clear if she is aware of today’s incomes for US doctors. I did not press her. I was too stunned to go on. She does have friends in the US that are doctors. My BIL was on vacation with us, he is an MD/Ph.D department head in a Boston hospital so she might have an idea of his pay.
Thank you for recommending this post to our Best of feature.
That we even have these discussions about the least bad deals for pharma in USA is proof of the insane disgrace of USA healthabuse system.
Whiners!
I had an eye exam two weeks ago where the doc found a cataract blooming in my right eye (that I had already self diagnosed) and a suspected baby just getting started one in left eye that I wasn’t aware of. She offered options for a surgeon with just over two years experience who could fix it in about 8 weeks vs the highly experienced over booked one that could do it in less than a year… maybe. She said I would hear back from the newbie in two weeks … today. Letter arrived with an appointment, all excited, opened the envelope and it was for an appointment made by my family doc for a completely unrelated test of my lung capacity that she does occasionally on a whim or when she needs the billing money? Next she will probably surprise me by sending me a requisition for a blood and urine test that we book ourselves online but with COVID and other issues the wait is 2-3 weeks.
Man it is hard to book vacations around some of this stuff. Wife is trying to talk me into a Med cruise or perhaps two weeks in the Algarve.
Tim
Gosh Tim, my cataracts are waaaay further up my list of priorities than yours are for you. Lucky for me my Mexican sculptor buddy’s cousin is the go to “highly experienced” expert of Mexico City and he has booked me for surgery in August. Canada and Mexico have it all over better than that murky flyover land in between. 
david fb
But when you went to Aetna mail order - the “in-network” price - they quoted you roughly $260 for the full year.
No. The most Aetna will dispense, mail order or at the pharmacy, is a 90 day supply. So it’s $260 for 90 days, $1,040 for a 1 year supply. That’s about triple the $346 I paid with GoodRX for a 1 year supply.
I don’t care how you slice and dice it, for profit health insurers are screwing you. They’re not acting like an agent, beating the bushes to find you the best price.
intercst