It's often cheaper to pay cash for your prescriptions rather than the co-pay, but the pharmacy is legally prohibited from suggesting it

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I fear that America’s Heath Care System (THE BEST IN THE WORLD!!! MAGA!!!) is simply the future of the UK’s health care system. It is a system designed by psychopaths, and our psychopaths have been taking notes.

Just look at the eyes. And remember, that’s an official portrait.


The less value that a middleman provides, the more protection he’ll seek out from the state if he has sufficient power and money. The U.S. health system has a lot of parasites, large and small, hanging off of it, and all of them are quick to cite the “free” market as justification for their businesses despite laws like this.


I want to thank BB for all news/discussion covering healthcare (despite it not being a “wonderful thing”) Many people have forgotten or remain ignorant that this is a major problem in this country that persists despite the tiny bandaid that Obama applied and left it completely unfinished with 25 states refusing to to make insurance possible for the working poor.

I’ve long known cash is cheaper at the pharmacy because there was no other option. You’d also be surprised how much cheaper you can get a script by calling around to half a dozen pharmacies, only takes about 15 minutes.

Currently my biggest healthcare problem is I’ve had shingles twice in my life (it’s the most painful weeks-long thing you can possibly imagine) and despite there being a new vaccine I could get, since it is on patent and no generic will be available for years, everything is priced to milk the magical insurance everyone is supposed to have. The shot is hundreds of dollars I simply do not have any given month. It’s rent or shot. Yay America.


Pharmacist here: can verify that this happens all the time. We call them “negative remittances” or “copay clawbacks”. These gag rules do not apply if you request a cash price - I just can’t volunteer the price.

Factual correction though - it is NOT state law that gags my speech - it is boilerplate language in the contract with the Pharmacy Benefits Manager (PBM). State law has been changed in most states now to prohibit this type of clause in a contract - allowing the pharmacist to volunteer that cash would be better than copay.

This situation exists because of the extreme market power of the PBMs. Three PBMs (CVS Caremark, Express Scripts, and OptumRx) control the payments for nearly 80% of prescriptions sold in the US. They threaten to remove my little indie pharmacy from their list of “network pharmacies” if I violate their contract in any way. This allows them to extract enormous rents from the system.

I can go on about at least 5 more tactics they use to extract these rents if you want - for brevity’s sake I’ll just name the tactics here - “DIR fees”, “formulary rebates”, “MAC pricing”, “specialty pharmacy”, “mail order mandates for maintenance medications.”

For more info, I suggest reading info from Pharmacists United for Truth and Transparency- or TruthRx - an indie pharmacist group that attempts to reveal the nasty tactics that PBMs use to extract rents from the system.


Special relationship, eh?


Forgive me for my ignorance, but what is the typical co-pay for insurance covered prescriptions in the US?

Up here in Canada, I pay $5 per prescription bottle, which is basically the pharmacy’s service fee. (so that’s $5 per prescription for most things, but $10 if the prescription is for dosage X and dosage y together). And the drugs are almost always more expensive than that.


It varies depending on the policy. Where I work, all copays and deductible payments are reimbursed, so it’s effectively zero. With my previous employer, it depended on the medication. It could be anywhere from $0 to $40 but some very expensive medications weren’t covered. For those, there’s often a program through the drug company and we took advantage of that a couple of times. For example, my daughter needed something that was $1300 for 21 day supply and it wasn’t covered. The drug company had a program that we were accepted into and we got the medication for free.


Copays for tier 1 drugs: generics, are typically $10 or less. Many plans then do $20 for preferred brands, $50 for non-preferred brands, and something like 40% coinsurance for “specialty drugs.”

The scam detailed in this article is that the PBM will contract with the pharmacy to pay the Pharmacy $3.50 for a certain drug, but will tell the pharmacy to sell it to the patient for their regular $10 copayment. The pharmacy is then expected to forward the $6.50 difference back to the PBM.

This is effectively a way for the insurance company to collect an additional premium on people who have pre-existing conditions which require drug therapy. It very clearly ought it be illegal for the PBM to do, but they threaten the pharmacy with cancellation of contract (or about 25-30% of revenue) if they tell the patient about it.

At least two state Attorneys General are suing the major PBMs for this behavior.


Just thinking out loud here…what would happen if you put up a generic sign that states “Cash prices for prescriptions may be lower than Co-pay, please ask your pharmacist.”


We could probably get away with that - but that would only help in my pharmacy. This is why my state and national pharmacy associations have pursued asking our state legislators to prohibit these gag clauses. A bill is in progress but has not passed yet.

I’ll put a plug here that independent pharmacies tend to have the lowest cash price in the industry - often lower than the “GoodRx” price, and MUCH lower than the cash price that you can get at a chain without GoodRx.



Note that an independent may also have the HIGHEST cash price… just have to find the right one.


@Steve_Jobs it’s inspiring to hear what you are doing in this space. When I lived in downtown Philly, I was always an avid customer of the independent Pickwick Pharmacy at 1700 Market Street. Google Maps


And note well that this is the guy who will try to wrest credit for NHS spending increases announced today from Boris Johnson (who will claim it as a Brexit bonus) so that when May falls, he (Hunt) will have public visibility and sympathy for ‘saving’ the NHS, sufficient to get him the leadership and the next election.
(‘Saving’ as in: throw the dog down the well and then decide a well is not the place for a dog and then pull it back out and be applauded as a great human being. Fuck him.)


My Costco pharmacy charges me the lowest price, whether it’s the co-pay price or the cash price, without discussion.


Cash is often shockingly cheaper for ER visits, too. In my experience, you’ll pay about 1/3 in cash as opposed to out-of-pocket costs WITH insurance.

My sister had mis-diagnosed gallstones turn into hepatitis/jaundice and required emergency surgery. After reviewing the bills and comparing it to the other family members* who had it done while insured, we were shocked to find out it was half as expensive with cash instead of insurance.

*Yeah, it definitely runs in the family, so we had a lot of samples for comparison.


Do they offer a discount for “off the books” work for actual cash-in-hand?

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I don’t know about that. We only go to the doctor if we have absolutely no other choice! The discount for cash is because it doesn’t involve the hundreds of man-hours of calling and arguing with the insurance company by the billing clerks.

If mechanics and garbage truck drivers and everyone else gives discounts for cash ‘off the books’, I can’t imagine that a doctor would turn his nose up at it. We all know how much doctors love taxes.


I imagine them having an RV parked just over the property line for cash-in-hand surgery.

“That’ll be five large; though I can drop that by half if you throw in one of them healthy kidneys you’re packin’.”

“Hey, Doc, do you have to wear your surgical mask just to talk to me?”

“Yeah, its better for both of us if you can’t prick me out of a line up.”

By the way, all the best to all you people struggling to survive the Corporate Medicare Experience.

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I suspect it’s not at all sketchy. Every woman who works for a doctor’s office gets herself ENORMOUS breast implants for super-cheap, even if the doctor is a pediatrician or podiatrist. I think they book you in and just write the billing as 1/10th the price or whatever.

I’ve seen some horrible hair implants on men, and overheard them explaining how their brother/neighbor is a rich doctor.

I know a drywaller who got his wife a doorknob of a diamond in trade for off-the-books work for a jeweler.