Tuesday, November 27, 2007

A Generic Update

[Welcome Industry Radar readers!]

About a month ago, Mike wrote about the disconnect between reality and prescription drug co-pays. Under Mike's current health plan, if a med costs $10, and the co-pay is $15, he actually has to part with the extra $5 if he uses his card. So of course, he simply says "nope" when asked about insurance, and gets that med for $10. He (and apparently lots of others) have also found the $4 deals (WalMart, Target, etc) to be a boon in this regard, as well.
One of our faithful readers took issue with Mike's assertion that he'd have to pay the full co-pay even if the med actually cost less. This reader (who wishes to remain anonymous, but for whom I can vouch credibility) wrote to let us know that his company, United Healthcare, generally doesn't ding their members in this way:
"I have now confirmed that UnitedHealthcare (my employer) IN FACT DOES only assume member responsibility up to the contracted cost of a covered service for BOTH medical and pharmacy claims. In short, we do not attempt to charge members a full copay for covered services like those involving $4 generic drugs at Walmart and Target when the contracted rate is less than the copay on covered services."
He adds that their most recent pharma contract language says:
"For Prescription Drug Products at a retail Network Pharmacy, you are responsible for paying the lower of:
• The applicable Copayment and/or Coinsurance or
• The Network Pharmacy's Usual and Customary Charge for the Prescription Drug Product."
Which would seem to indicate that under those plans, if the scrip was $10, you'd pay $10.
Of course, these all apply to commercial, insured plans, not ERISA (self-funded) ones. Generally, ERISA plans can include pretty much any language the employer wants, which means that the minimum co-pay amount charge could be required in such a plan.
I'd really like to Thank our anonymous source, and would challenge other carriers (we know you read us!) to chime in.
blog comments powered by Disqus