2. Prescription Drug Coverage — How It Works and Why It Is Broken
Prescription drug coverage became part of standard health insurance as drug costs rose. Before the 1960s, most medications were affordable out-of-pocket. As costs climbed, coverage became expected.
How Our Plans Handle Prescriptions
Our plans do not include a traditional prescription insurance card. Clients will not show an insurance card at the pharmacy. Instead, they use GoodRx — a free discount card — and pay out of pocket at the time of purchase.
- Pre-existing prescriptions (medications the client was already taking before enrollment) are not covered for the first 12 months
- After 12 months on the Optimum plan: $10 reimbursement for generics, $20 reimbursement for brand-name medications
- Reimbursement only — client pays at the pharmacy, then submits for reimbursement
- A generic drug might cost $10 at wholesale — but carry a $50 copay through insurance due to opaque PBM pricing
- Clients pay more out of pocket on insurance than they would paying cash
- PBMs prioritize rebates and profits over patient savings
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This Is a Talking Point When clients ask about prescriptions, you can explain that our plans do not include prescription insurance — and that this is actually a feature, not a bug. There is no traditional insurance card to show at the pharmacy. Instead, direct clients to GoodRx, where they will often pay less out of pocket than they would with a traditional Rx benefit. Most common generics run $4–$10 through GoodRx — cheaper than most insurance copays. |
The PBM Problem
The prescription system today is heavily controlled by Pharmacy Benefit Managers (PBMs) — middlemen who sit between insurers, pharmacies, and drug manufacturers. PBMs negotiate pricing, but those negotiations often benefit the PBM rather than the patient.
Cost-Saving Alternatives — Direct Clients Here
These tools work alongside our plans and often beat traditional insurance pricing entirely:
|
Tool |
How It Works |
Notes |
|
GoodRx ✓ |
Free discount card/app — shows lowest local pharmacy price; accepted at most major pharmacies. This is our primary recommendation for clients. |
Direct all clients here first |
|
Lone Star Rx ✓ |
Transparent pricing, direct delivery — this is our second primary recommendation after GoodRx and the main one we direct clients to call besides GoodRx |
Direct clients here if GoodRx does not meet their needs |
|
Cost Plus Drugs |
Sells generics at cost + 15% markup + $5 shipping — bypasses PBMs entirely |
We do not work with this company and rarely refer clients here — exists as a backup option only |
|
Scriptco |
Membership-based pharmacy; wholesale pricing; often 80% below retail |
We do not work with this company and rarely refer clients here — exists as a backup option only |