Is this a really boring drug ring?

September 15, 2016 2:29 PM

How is a pharmacy providing me a prescription for free that isn't covered by my insurance?

I got a prescription from my (new) dermatologist for a topical that my insurance doesn't cover. My CVS pharmacist was told pre-authorization was required so I called the dermatologist. Instead of going through pre-authorization, they sent my prescription to their "specialty pharmacist" and told me that this pharmacy would work with the insurer and if that didn't work out the pharmacy could offer me my prescription for a reduced fee. The pharmacy just called, and the insurer is still balking so they are going to provide me with my prescription for free, including the shipping costs (they are located in Virginia, I am in DC). This is a prescription that retails for over $500. How is this possible? What system is in place here? I don't want to tempt fate since this has worked out incredibly well, but I'm quite curious about the mechanism at work.

posted by HonoriaGlossop to Health & Fitness (7 answers total)

Many pharma companies have programs that provide their medications for free or greatly reduced cost to those who are not covered by insurance. They make enough from insured folks to cover the cost (see the recent upset about the rise in price for Epipen and then google Epipen coupons). Good pharmacies will help locate those for you. It's very possible that you found a good pharmacy.
posted by goggie at 2:51 PM on September 15, 2016 [4 favorites]

There are various programs:

http://rxassist.org/

Patient assistance programs are run by pharmaceutical companies to provide free medications to people who cannot afford to buy their medicine. RxAssist offers a comprehensive database of these patient assistance programs, as well as practical tools, news, and articles so that health care professionals and patients can find the information they need. All in one place.

How to Get Free Prescription Meds
posted by Michele in California at 3:00 PM on September 15, 2016

I can't answer your question about how prescription prices are deterimed*, but for future reference, you can get often get similar jaw-dropping differences in prices by using goodrx, which costs you nothing.

Last summer a family friend paid ~$450 for Zyprexa at the local CVS and later learned that the goodrx price at CVS was ~$150.

The goodrx price for the exact same prescription at Walmart was $14.


*Though given what makes the news, I would bet hard money that it has little to do with the cost of developing and manufacturing the meds and that anything resembling human decency is removed from consideration.
posted by she's not there at 3:05 PM on September 15, 2016 [2 favorites]

From an economic standpoint, the pharma companies basically have every incentive to provide drugs at low prices if they can't gouge an insurance company. The marginal cost to manufacture a drug for one patient is tiny -- all the real cost goes into the fixed up-front cost of drug development. So giving away a drug or selling it cheaply to a patient who would otherwise do without doesn't cost them much. Hence why pharmaceutical companies tend to have these programs that provide a drug very cheaply if you can show that you don't have insurance or that your insurance won't pay for it.
posted by mister pointy at 3:08 PM on September 15, 2016 [1 favorite]

Best answer: Have you followed or heard anything about Valeant and the scandal that has unfolded there, which has specialty pharmacy at the heart of it? In addition to using/owning specialty phramacists, Valeant also uses patient assistance programs. They also have a big portfolio of dermatological drugs.

The details are not clear to me, but I believe the idea is thus: 1) acquire a drug with high market share and low price, 2) raise the price aggressively and/or use specialty pharmacies to do things like sell a three month supply when only one month is needed, 3) when insurance companies start pushing back, subsidize the cost using patient assistance programs so that the actual "price" of the drug isn't marked down.

How step #3 plays out is somewhat of a mystery. It seems like a way to buy time. In the near-term, they fight off the stingy insurers while gouging those who haven't clued in yet. There may also be accounting shenanigans going on (e.g., they recognize full-price of the drug as revenue but bury the patient assistance expense in some manner that inflates earnings) but I'm only guessing. They also don't want to lose market share. Your insurance company may not be paying up now but if no other manufacturer can supply the drug for cheaper, perhaps the insurer eventually gives in.
posted by mullacc at 3:45 PM on September 15, 2016 [3 favorites]

Have you followed or heard anything about Valeant and the scandal that has unfolded there, which has specialty pharmacy at the heart of it? In addition to using/owning specialty phramacists, Valeant also uses patient assistance programs. They also have a big portfolio of dermatological drugs.

Yep. I had a situation like the OP when my dermatologist suggested I try Jublia (which is a Valeant drug). She had a coupon for "no co-pay" for the first bottle, but then subsequent bottles might cost. I had to call the Valeant pharmacy and the prescription was filled by them via mail. I never refilled it but apparently now they are using Walgreens to fill these types of prescriptions instead of their own specialty pharmacy.
posted by candyland at 4:30 PM on September 15, 2016

Response by poster: Sure enough, it is a Valeant drug.
posted by HonoriaGlossop at 5:20 PM on September 15, 2016