Recently, I filled a prescription at my local pharmacy for a maintenance medication—a drug you need to pick up every three months. I am fortunate to be covered under two plans: my employer’s and my spouse’s employer’s plan. While neither plan covers 100% of the cost of drugs, between the two plans, my spouse and I have never actually needed money when we visit the pharmacy. But on this particular visit, I suddenly needed $2.10!
Not a big deal…except, in our almost cash-less society, I rarely have money in my pocket. And since I don’t typically have to pay for anything at the pharmacy, it’s easy to run in without plastic, too.
So, as this was an unusual situation, I questioned my pharmacist. She happily gave me a breakdown of what was paid by which company the last time this prescription was filled versus what was paid this time.
Then I contacted my insurer, who quickly reminded me of a newsletter I received back in September, advising me of a change in the reimbursement process. I didn’t really need the reminder—but I did need an explanation of how the change impacted me, when their newsletter said it wouldn’t.
In a nutshell: the coordination of benefits process has changed slightly. The second payer for this claim used to simply pay the amount not paid by the primary carrier. Now, the payer is applying its own pricing limit to the claim and paying the difference between what was paid by the primary carrier and the limit. Insurers’ pricing limits for drugs are determined by applying a reasonable markup to the manufacturer’s price for a drug, and pharmacies across Canada agree to these limits as a condition of participating in the direct reimbursement program.
In my case, the insurer’s price limit was $2.10 lower than what the pharmacy was charging. When I contacted the insurer to question what had happened, the insurer contacted my pharmacy and confirmed the pharmacy charged that $2.10 in error, so I would receive a refund.
It made me wonder, though: how many people are paying the pharmacy in excess of their agreements with the insurers? How many employer drug plans are paying the pharmacy this excess?
While it’s only $2.10 to me, my usage is fairly low, and I can afford it. But others can’t. Is it better when this is paid by an employer plan? As insurers charge expenses or premiums based on claims experience, the $2.10 I would pay actually costs my employer more (forgetting the impact of taxes).
Keeping benefits plans affordable is the responsibility of plan beneficiaries, employees, employers, service providers such as pharmacists and physiotherapists, and insurers. My insurance company took a small step in the right direction, and I applaud them. Now we just need everyone else to join in.
In the interest of my good health, I won’t use my $2.10 credit to buy candy at the cash register—but my pharmacist can rest assured that some other shiny object will catch my eye. That credit will never make it out of the store.
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