This would be for:
- all insurer formulary drugs not having insurer fixed co-pays and
- non-formulary drugs, with a reimbursement rate of no more than a pseudo-random percentage from 80% to 90% of the insurer’s cost of a similar or comparable (in its eyes) formulary drug
Similar or comparable in the insurer’s eyes might be:
- a recombinant drug of comparable complexity and comparable total prescription volume worldwide or
- a drug of similar chemical structure or comparable complexity
- a member in the same or similar or comparable drug chemical class
- a similar or comparable drug used to treat a condition or disease the insured has or might have
Insured persons would pay an insurer/(pharmacy or pharmacy benefit manager)/drug maker price upfront.
Lower income people could use a drug purchase assistance debit card to pay some or all of the cost:
- The pharmacist would enter (the cost of) the prescription and the card number over the Internet or use a phone.
- A government agency (and drug maker for more expensive drugs) would put money on the card on the back end.
- The pharmacist would swipe it.
Maximum out-of-pocket insured persons could also get and use a similar card and system.
At the beginning of each month, for each primary care doctor (and formulary group and plan):
1. the insurer would add up the money paid upfront by its insureds (and government patient assistance) in the prior month
2. then the insurer would add up its costs of the prescriptions in the prior month
3. then the insurer would then divide the total paid upfront by the total prescription cost to get the plan reimbursement percentage for that primary care doctor (and formulary group and plan) for the prior month.
If someone paid $90 for a prescription and the reimbursement percentage was 60%, the insurer reimbursement for the prescription would be $54.
Primary care doctors would have a modest, but not excessive, incentive to prescribe in a cost effective manner in order to ensure their reimbursement rate was high.
Only primary care doctor prescriptions would get reimbursed at the full percentage. Specialists would request primary care doctors write the prescriptions. This would keep the prescription database for the patient normally in one place and quite accurate.
The insurer might allow reimbursement of specialists’ prescriptions, but at say only at 90% of monthly computed reimbursement rate.
The prescriptions written by each specialist of the insured would be used in the base calculation of the total prescription cost for the primary care doctor of the insured.
An insured person would always prefer that their primary care doctor wrote all their prescriptions.
This system is based on primary care doctors because medical specialties have widely varying prescription needs and costs.
If it was based on specialty doctors the reimbursement percentages would vary a lot.
Reimbursements would go out monthly on about the second Tuesday of the month in the following priority per insured to:
- the government agency
- the insurance company itself if the insured and/or policy holder owes it money, to the extent to which it is owed
- the insured’s HSA
- the insured’s drug debit card
- the policy holder by check if the policy was bought on the federal exchange by buyer(s) in a household under 200% of FPL
- the policy holder by check if over $100 or
- the policy holder by check if the policy term is up
Reimbursement would never be computed on drug maker assistance, only on insured and government prescription payment. Having the drug maker say pay $40 and get say $64 (the original $40 paid upfront + $24 [$40*.6] more) only helps the drug maker.
It would also be possible to say add 5% to the reimbursements of formulary drugs and then reduce the reimbursement percentage of non-formulary drugs.
Prescribers would generally be more careful about drug costs even if many of their patients aren’t in such plans.
This type plan would be preferred by employers looking to cut their drug costs.