The price you pay at the pharmacy is going up — again. Prices increased on more than 250 drugs in the beginning of the year, with an average jump of 6.3 percent, according to data from Rx Saving Solutions, a consultant to health plans and employers. That's down from the 400 drugs that saw price jumps last year, but prescription drugs still remain one of the highest out-of-pocket medical costs for many consumers.
This in spite of several Trump administration initiatives over the past weeks designed to lower the cost of prescription drugs. In addition, House Democrats joined the fray last week with sweeping investigations of pharmaceutical drug-pricing practices.
As Washington continues to wrestle with the pharmaceutical industry, consumers may actually find the most relief from their own efforts. Understanding how drug pricing works and learning to navigate that maze can result in dramatic savings. Here's what you need to know.
Your insurance isn't always the best option
Sometimes you may be better off paying cash for a drug than using your insurance. That sounds counterintuitive, especially because so many consumers, especially Medicare Part D recipients, spend hours trying to find insurance plans the cover the drugs they use.
But often a pharmacy will offer a discount on a drug that makes the cash price cheaper than the co-pay your insurance company or pharmacy benefit manager (PBM) has negotiated for the same drug, be it brand name or generic. For example, a common generic for Lipitor, the cholesterol lowering medicine, comes with a standard $40 co-pay under many plans. But at some pharmacies offering discounts, the total cash price of the drug may be only $9.
What's more, until very recently, pharmacists were prohibited from telling you about these price differentials because they were under contract not to say so with various PBMs.
Last October, the Trump administration passed new rules barring these gag orders. Now pharmacists may tell you about cheaper alternatives, but — and this is the catch — they don't have to volunteer this information. Your pharmacist is only obligated to tell you if you ask.
So, every time you fill a prescription covered by your insurance be sure to ask your pharmacist what is your co-pay, and, importantly, what is the retail price of the drug. The answer will make it clear which way to go because now the pharmacist must offer you the best price.
Meanwhile, your prescription drug insurer may push you to go to a certain pharmacy, chain store or mail order service to fill your prescription because they have negotiated lower prices overall with a certain vendor. That makes sense. But again, it may not be the best deal when you consider other prices and discounts.
The recent rift between Walmart and CVS Caremark pharmacy benefit management, during which the two companies butted heads over drug pricing, is evidence of how volatile the prescription drug landscape can be. "Always compare the preferred pharmacy price with others in your area," said Dr. Nancy Simpkins, Rx Saver's medical expert. "Preferred can be a misnomer. It doesn't necessarily mean cheapest."
You might get a better deal across the street
Insurance aside, many times consumers simply don't realize just how much that the price of drugs can vary from one pharmacy to another, even in their own zip codes. That's because each pharmacy negotiates its own contracts with PBMs for multiple drugs.
Enter the new array of smartphone drug pricing apps, including GoodRx, OneRx, RetailMeNot Rx Saver, and ScriptSave. Plug in the drug you're looking for and you'll find a list of prices at pharmacies in your area. In some cases, you may find additional discounts generated by the apps themselves.
Bottom line, that's a lot of shopping. To find the absolute best deal, you need to compare not only among pharmacies in your area but also among the deals offered by each of the apps. That can get a bit time consuming, but in many cases the savings warrant it.
There are caveats. For one, apps are frequently updated and discounts change often. The deal you get this month on say, that Lipitor generic 'script, may not be available for the same price at the same pharmacy next month. In other words, you have to go hunting all over again.
Also, most doctors usually phone in prescriptions rather than write out an order on their pad. If the prescription is automatically sent to your regular pharmacy but you find a better deal elsewhere, you'll need to call your regular pharmacy and ask them to transfer the prescription. They will do it willingly, but it adds an extra step. Simpkins suggests going retro and always asking for a hard copy of your prescription so you can have more flexibility.
-- The Associated Press contributed to this article
Starting on January 1st small businesses may have another option when looking for affordable health insurance solutions. Association Health Plans allow unrelated companies to band together to purchase health insurance at hopefully lower rates.
AssociationHealthPlans.com has assembled the following information to help small businesses decide if this might be an option for their situation.
Here are five things to know:
1. These are not Affordable Care Act plans, and their benefits may differ.
While the regulation allows associations to design health plans around employee needs and employer budgets, association health plans do not have to offer all of the essential health benefits required by the Affordable Care Act. However, large group association plans are still subject to state benefit rules as well as numerous federal benefit requirements relating to issues such as maternity care, pre-existing condition coverage and preventive care. Association health plans must also provide a Summary of Benefits and Coverage that describes insurance features in "plain language."
2. New options are available Jan. 1.
The new association health plan regulation has an effective date that is staggered. Jan. 1 is the date that existing associations may launch self-funded health plans under the new regulations. These plans can have even lower costs than fully insured plans because an insurance company does not make a profit off their coverage, and the plan is not subject to normal health insurance taxation.
New fully insured (meaning they are insured by a third-party health insurer) plans became available Sept. 1, 2018. New self-insured association health plans will be available April 1, 2019.
3. Large group association health plans cover pre-existing conditions and cannot deny coverage or raise premiums based on an individual's health status.
Multiple federal regulations apply to association health plans. Among the rules governing these plans is the requirement to cover pre-existing conditions within any Essential Health Benefit category included within the insurance plan. Additionally, people eligible for association membership cannot be denied insurance based on health factors nor can their premiums be increased due to health factors.
4. Part of the gig economy? You can qualify, too.
One of the major changes to association health insurance under the new regulation is its ability to cover self-employed individuals who are not part of a business with other employees. And you don't have to be incorporated. Informal work — such as handyman work, tutoring, music lessons, etc. — would be just as legitimate as independent contracting for a company.
5. There are new provisions to discourage fraud and mismanagement.
Because the history of association health plans includes examples of mismanagement and fraud, the new regulation incorporated a series of measures to promote sound governance and solvency. These measures include the requirement that the association health plan be controlled by the employers making up the association. Insurance companies, medical providers and other entities with conflicts of interest are prohibited from controlling an association health plan. Vendors performing services on behalf of an association health plan (e.g. record keeping, compliance, marketing, etc.) are prohibited from receiving more than reasonable compensation for these services. There is also a class of prohibited transactions that prevent self-serving transactions that work in the interests of an association employer or affiliate rather than the plan and plan participants.
AssociationHealthPlans.com is the leading online resource supporting the emerging association health plans market. AssociationHealthPlans.com is headquartered in Nashville, Tennessee.
CONTACT: Amy Fletcher Faircloth
With all the talk about repealing the ACA and the "individual mandate" penalty going away next year, business owners might think they are off the hook to comply with all the ACA laws. This is not the case, nothing has really changed if you have more than 50 full time equilvalent employees.
The number one thing to be aware of is providing "qualified, affordable health insurance" is still the rule of the land and not complying can cost you dearly. The IRS is enforcing "employer shared responsibility payments" (ESRP) penalties against large employers who fail to meet the ACA requirements.
The IRS is assessing penalties using 226-J letters
This letter explains that the employer may be liable for the penalty, based on information obtained by the IRS from Forms 1095-C filed by the employer for that coverage year and the tax returns filed by the employers employees. If an employee indicates on their taxes that the coverage offered by their employer is not affordable it can trigger the penalty by the IRS. The employer has only 30 days to respond to the 226-J letter, using IRS form 14764, which is enclosed with the 226-J letter. Not responding to the letter in the 30 day limit will result in a final assessment of the proposed penalty.
The penalties of non-compliance can be severe. In the worst case, an employer with inadequate or unaffordable health insurance could pay for the cost of the coverage as well as penalties of $2,000/year for every full-time employees (less 30), even those who received health coverage from the employer.
The real key here is to reply in the 30 day limit and make sure the lowest cost plan does not charge employees more than 9.56% of an employees income.
We have a new group health insurance product in Middle TN beginning January 1, 2019. Oscar Health who last year partnered with Humana to give small employers a new "high tech" option for health insurance is now a stand alone carrier. While Oscar looks like a traditional health insurance company on the outside, they do everything possible to break the mold of the traditional carrier and hope technology and customer service will reduce costs and improve satisfaction.
Oscar's main interface is through their cell phone app. On the app you can look at claims and find a doctor but you can also make a doctors appointment and more importantly talk with your personal representative who can assist in finding the right doctor and appointment. Their "talk to a doctor" feature is easy, seamless and free on most plans.
Most middle TN hospitals are in the network and they are adding more doctors on a weekly basis. For a new carrier the local network is quite strong. Here again, the work somewhat differently in that you do not have benefits if you go out of network. That is something you should not take lightly and be sure to do your homework before seeing a new provider.
Premiums are regulated by the state and are community rated just like the other carriers in the under 50 employee small group market. You have many different benefit options and premiums are lower than many of the other carriers. There are no pre-existing conditions as these are ACA compliant plans.
Oscar Health is available in middle TN only. If you have employees who live outside of this area or are traveling out of state you can access the Humana CHC network which is a great national network of doctors and hospitals.
Want to see a quote for your company? We will be happy to show you options and prices. Call David at 615-724-1699 or email firstname.lastname@example.org
After four years of double digit increases for individual health insurance plans, BlueCross BlueShield of Tennessee is lower rates by an average 14.9% next year. Cigna is also reducing premiums by an average of 12.9%. What does this mean for consumers? Time will tell, 3.5% of Tennesseans get their health insurance through healthcare.gov and most of those receive substantial subsidies so they actually pay very low rates to start with.
Our hope is these reductions will also come to our small group clients who have Essential Heath Benefit "EHB" health plans with community rating. This would provide a huge financial relief to hundreds of thousands of working Tennesseans who get their insurance through their employers.
There are many new health insurance options available for small and mid sized employers who have a healthy workforce and good participation. We have helped many clients with "level funding" and "limited funding" options which blend fully-insured and self-insured health plans to reduce costs, provide plan design flexibility and have full claims transparency. If you have not seen a level-funded quote for your company we would much appreciate the opportunity to explain how these new policies work and the advantages in specific situations.
You can reach me at email@example.com for more information.
Oscar Health the startup health insurance who uses high tech and high touch to differentiate themselves from traditional health insurance companies is bringing on a huge partner. Here in Nashville, Oscar Health had partnered with Humana to offer individual and small group medical plans. They agreed to part ways for 2019 but it seems we have only seen the beginning of what Oscar can do.
Oscar plans to use the money to enter into the lucrative market for private Medicare Advantage plans for seniors. These are a type of Medicare Supplement.
As for small group health plans we can only hope they continue to expand in Tennessee to give consumers more options and hopefully at a competitive price.
More great news for Tennesseans who are covered under the health insurance marketplace. It was just announced that BlueCross BlueShield of TN will be reducing rates by an average of 15% in 2019. Cigna, the second largest carrier in Tennessee will be dropping rates by nearly 13%.
We were expecting lower health insurance costs next year but with the announcement from the Trump Administration that they will allow the "risk adjustment payments" the carriers risk level was reduced.
What will this mean for small groups have are covered under group Essential Health Benefit "EHB" plans? We can only hope we see similar decreases.
It's been a long time since we could say "your rates are going down" rather than "rates are going up and so is your deductible". We have wondered where the tipping point will be for affordability for consumers and profitability for the insurance companies, maybe we have finally reached it. This morning as I watched the news which is full of commercials promoting $5,000 per month medications that are "free" to consumers if you have commercial insurance, I scratch my head and wonder when the madness will stop. Well it's not stopping but at least it may not cost as much next year.
In August, 2018 BCBST reduced their base rates in the middle market for Tennessee group insurance customers by around 15%. This was HUGE and a tremendous relief to hard hit businesses and employees. Now it looks like the small group EHB plans and individuals will see some rate relief for 2019. Those rates are filed annually and can't be changed until January 1st. BCBST is proposing an average decrease of 10.9% and Cigna will reduce costs by an average of 4.8%. We should know what small groups are getting by early August, my fingers are crossed.
Obamacare changed the rules when it forced insurance companies to offer coverage with no exclusions, limitations or pre-existing conditions. The carriers did not really know how to price a policy like this and BlueCross BlueShield of Tennessee came out with some really attractive rates. After loosing hundreds of millions of dollars the incremental increases trippled the premiums. In 2015 rates increased by 19%, 36.3% in 2016, 62% in 2017 and 21% in 2018. Cumulatively, that is a 318% increasing taking a $100 monthly premium in 2014 and costing nearly $318 today.
For the small business owner the increases have not been that extreme but it's still been very painful. I had a group who recently tried to offer a group medical plan to their employees only to have all 10 employees say they could not afford or did not want the plans. The company was going to pay 50% of the cost but still it was unattractive to the employees, that is not a good thing.
The ongoing battle over high prescription costs is taking another turn. With many specialty prescriptions costing $5,000 per month or more, drug companies figured out by offering pricing assistance until an employee hits the deductible, they could sell a lot of drugs. This created a tremendous challenge for insurers trying to control costs in light of all the direct to consumer advertising.
The latest move by insurers - effectively forces drug companies to pay more to assist patients with their copays - is causing a decline in real US drug prices this year for those companies adopting the strategy and is expected to become more widely adopted in 2019 and beyond.
The good news is this can slow the ever increasing cost of healthcare. The bad news is employees and patients who really need these expensive drugs can find themselves unable to afford them.
Essentially what the "copay accumulator" does is prevents the copay card funds from counting toward a patients out of pocket maximum. Once the out of pocket maximum is reached the insurer pays 100% of the costs and the employee / patient has 100% coverage for all medical and pharmacy costs the rest of the year.
Drugmakers are not taking this in stride and are trying new methods to avoid detection.
President Trump signed a new rule making it easier for small businesses to join forces and set up health plans that avoid many of the expensive ObamaCare rules. The new plans will be called "Association Health Plans" and they could be available as soon as September, 2018.
What do these news plans look like? No telling since they are not able to deny coverage or charge higher rates for pre-existing conditions. These are two of the things that drive up costs in the small group market, so what's different about the new plans? That is a big question and based on what I am reading I don't see the attraction for the insurance carriers who are risk averse to begin with.
For many small groups "Limited Funding" a type of self-insurance can accomplish what we think the Association plans are trying to do. "Limited Funding" plans allow you to underwrite your group medically and if you are healthy, you can qualify for much lower rates than the ACA pricing. This strategy has worked very well for many of our groups but you have to be healthy for it to work.
More to come, at least they are trying different ideas to see what might work bring costs back down.