January 14, 2009

Can You Compute the Cost of a Prescription

I called my health insurance provider to try to figure out what is the actual cost of Rifaximin to me. I learned some time ago that it's less than what I pay at the pharmacy. Here's why:

After we meet our yearly deductible, we start getting refund checks from Anthem (our insurer) for prescriptions. It appears that they were reimbursing 60% of what we had paid. I called them today to confirm this.

Yes, after we meet our deductible, they pay 60% of the allowable amount on prescriptions. By using a participating pharmacy, we are only charged the allowable amount or less when we pick up the medicine. However, if we get a lot of prescriptions, Anthem stops paying after they pay $5,000.

It gets more complicated if we reach the out-of-pocket maximum like we did last year. At that point, the co-pay is dropped and we are reimbursed 100% until the $5000 limit is reached. (This would only happen if most of our expenses were non-prescription, since the out-of-pocket maximum is $6000 for all allowable expenses. Have I lost you?) But let's forget the out-of-pocket thing since we don't usually reach it, nor have we ever reached the $5000 limit on prescriptions.

Anyway, since there is no way of predicting how much of our deductible will be made up of prescriptions versus doctors and tests, there is no way of knowing how much of each prescription applies as a credit toward the deductible. To get a general idea, I used a couple of scenarios and found that my actual prescription cost runs (over a year) 49% to 67% of the price paid at the counter. Considering that we've had three medical tests already for 2009 (at two weeks!), and that I'm racking up $146 weekly in allowable physical therapy alone, we should meet the deductible pretty early this year. (Last year we met it in April.) Anyway, I estimate that for a prescription costing $250, we are actually paying around half, which is still a lot of money.

For my reader who is a benefits professional: am I correct in thinking that submitting prescriptions before we meet our deductible is actually more beneficial than submitting them afterward, since our co-pay on prescriptions is 40% and our co-pay on office visits is only 20%, but as far as meeting the deductible all expenses are credited at the same rate? I'm no mathematician, but if I can get a little extra out of health insurance, I get a little thrill.

1 comment:

  1. Wow. Your reader who is a benefits professional is way more confused than you are. But, I promise to give it some thought and get back to you once my head stops spinning.
    Not that it matters for answering your question, but how much is the deductible?


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