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Prescription drugs copay and deductible, how to optimize?

Dear experts,

I would like to ask a question about minimizing total out of pocket cost for medical coverage for a given insurance plan. The plan classifies all prescription drugs in three tiers: 1st tier (generics, $10 low copay), 2nd tier (brand name formulary, $35 copay), 3rd tier (brand name, non-formulary, $75 copay). On top of that the plan imposes a $100 annual deductible. Such plans are pretty common, as far as I know.

Because there is a deductible as well as a copay, early in the year the copay (defined by the drug) and the deductible work together to determine the out of pocket cost of the prescription in the drug store. I've heard that precisely because the deductible and the copay in this case work in combination, the total out of pocket cost of the visit to a pharmacy to fill several prescription at the same time would be affected by the order in which they are billed to the insurance by the pharmacist.

Namely, if the pharmacist bills the cheaper medication first and the more expensive medication second, the out of pocket cost would be different from what it would have been if the pharmacist billed a more expensive medication first and, only after that, the cheaper one.

Could someone explain the difference and give advise on that matter?

Thanks in advance...
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282113 tn?1388163349
Dear Stan7a,

Usually the pharmacist should do the math to process and fill your prescriptions in a prudent way. The difference however are not significant; in short, if the cost of your medication turns out to be greater than your deductible plus your copay (for that tier), then you will not only have to pay your deductible but also the copay for that 1 prescription.

In case you are prescribed multiple prescriptions at once (prior to meeting your deductible), the pharmacist will have to determine which one of the prescription (or prescriptions) should be used to meet your deductible.

The variables are too many due to tiers and negotiated rates of each medicine to create a set of simple rules.


Amir Mostafaie      
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