Medicine not in formulary. Their clinical department decided it was not worth covering for $reasons. The Pharmacy, likely to be considered a preferred pharmacy, signed a contract to be bound by that company's clinical formulary for policyholders.
$45 was probably cash price, the they can let it go for if they do their ordering through a pharmacy supply group.
$12 may be a price with a discount program like GoodRx applied. Data changes hands behind the scenes to make the lower price at the till possible. Don't know how GoodRx works, but been around long enough to know you're probably the product.
You'll be amazed the complexity of the pharmacy benefits management complex.
t. Been there, seen it, tried to fix it best I could, left in abject horror.
Turns out there are rational commercial players in these markets if you just go all-cash. The price is abandoning the incantations and local pharmacies, hospitals, ignoring your insurance. Harder to do that with services, but it’s coming as well.
You did nothing from their point of view except waive having them cover the claim, thusly leaving more money on their hands to be managed longer. Your "price discovery" isn't something they aren't aware of. On the contrary, their surveillance/clinical team have been crunching the numbers and making unilateral decisions on how the population is best guided to drugs based on their bottom line benefit to the insurer.
You don't really factor into it except as an actuarial data point. But you might have kicked off an overpayment check back to the consumer in 12 months because golly gee, those pesky regulations! Don't worry though, you can hand it back because the premiums went up again!
I found another really interesting one when my wife needed $30k in dental surgery. We hurried up and got the American marriage so that they could use my dental insurance only to find out that my plan has a LIFETIME LIMIT OF $1200. But what came to our rescue was good old collective bargaining! They call it a discount plan and basically the way it works is that for a small fee an insurance company will essentially draw you up a plan that counts you as a member but where the insurance company is explicitly not liable to pay for anything at all under any circumstances. The practical upshot is that you as a new Crap-Tier member of this insurance plan get the same negotiated rates as everyone else on this insurance plan, including the ones who pay through the nose. You still have to pay everything out of pocket, but to use this as an example "everything" went from $30k to $18k with the stroke of a pen and $50 in signup fees. This is one of the few things that an insurance company is doing that I think is actually great. The rates are exceedingly reasonable, the upside is amazing and because it's not technically insurance there's no pesky BS about open enrollment or you have to be married or you can only use it if your costs are above x once you've paid y and only if you've spent more than z this year but less than alpha your entire lifetime etc. Purely and simply walking into the office and going "Hey, there's ten thousand of us. Give us a fair rate and gain ten thousand customers or don't and don't."
> Don't know how GoodRx works, but been around long enough to know you're probably the product.
- GoodRx was penalized $1.5m by the FTC 2/2023 [0] for sharing sensitive personal health information with third-party advertising companies (Facebook, Google, et al), without user consent. Then in 2024 it paid a $25m settlement arising from that action [1].
- GoodRx isn't subject to HIPAA, it can legally share "non-medical" information, i.e. your prescriptions, which often have a one-to-one (or one-to-few) correspondence to specific conditions. Hence, sidestepping HIPAA.
- its business model relies on collecting user data, which may be a concern for privacy-conscious individuals.
this is actually what it's like getting pants hemmed at men's wearhouse once the salespeople realize you won't be paying their rent today with the commission on a big purchase. I needed them in a week. Dude quoted me 3 weeks, then 10 days, then 8 days, then said he could get it done in 15 minutes. I get that under the hood capitalism is about charging the most you can get away with and offering the least the other guy will expect, and he's supposed to do the same and y'all strike a middle ground that makes nobody happy but is acceptable to everyone. But you're not supposed to flat out look at me and go "What's the worst you'll accept from me right now?"
Me: "Okay, what if we don't go through insurance?"
Pharmtech: "$45 for the prescription."
Me: "That's a bit higher than last time."
Pharmtech: performs some sort of incantation "Okay, $12."
Me: "How did we go from not at any price to $12?"
for those of you keeping score at home, the medicine was generic colchicine which costs $.30/dose (https://pmc.ncbi.nlm.nih.gov/articles/PMC7851728/), and I was getting 12