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For common generic cardiovascular drugs, paying out of pocket at Walmart may often be more budget friendly than Medicare prescription copays, according to a research report.

A median 21% of Medicare plans had patients pay more out of pocket for a 30-day supply than Walmart's $4 generic discount program price, as reported by Joseph Ross, MD, of Yale University School of Medicine in Connecticut, and colleagues in the .

Even for tier 1 preferred generics and select care tiers in which cost sharing is supposed to be low or nonexistent, the median proportion over that $4 out-of-pocket threshold was 19.9% for Medicare Advantage plans and 1.9% for standalone Medicare prescription drug plans (PDPs).

In other tiers, 95.6% of the drugs' out-of-pocket cost surpassed Walmart's price under Medicare Advantage and 48.9% under standalone PDPs (P<0.001).

"Never assume that, just because a particular drug is on the $4-per-month formulary, that your patient will not have to pay more out-of-pocket money to obtain this medication," William Elliot, MD, PhD, chief of pharmacology at Pacific Northwest University of Health Sciences in Washington, commented to 番茄社区 on the analysis, in which he was not involved.

The consistently higher cost sharing in the Medicare Advantage plans was "counterintuitive" compared with plans that solely cover pharmaceutical services, the investigators noted.

"We generally think of [Medicare Advantage] plans as having stronger incentives to care about the non-pharmacy implications of patient adherence (e.g. hospitalizations, ER visits), because they cover those costs as well," agreed Karen Van Nuys, PhD, of the University of Southern California's Center for Health Policy and Economics in Los Angeles, who was not involved in the study.

The implication is that that insurers are profiting by "paying less than the patient's copayment to settle the claim with the pharmacy, and pocketing the difference," she commented to 番茄社区, as "the availability of these drugs for $4 at Walmart is implicitly used here as an upper bound on what PBMs [pharmacy benefit managers] must be paying to settle these claims -- if a patient off the street can fill the script for $4 at Walmart, a big PBM with all their negotiating leverage probably isn't paying more than $4."

The investigators reviewed 2,155 Medicare PDPs, of which 28.9% were standalone PDPs and 71.1% were Medicare Advantage plans. Using Walmart's 2017 generic drug discount program list, the investigators selected 27 generic medications used to manage common cardiovascular conditions. Medicare PDPs covered a median of 25 of those prescriptions.

The investigators acknowledged that they did not "know the number of beneficiaries enrolled in each plan or the generalizability of our findings to other drug classes."

As for future research, Elliot said, it would be interesting to see how the authors' findings could be changed by President Trump's efforts at price reductions for prescription pharmaceuticals.