By Forest Park Pharmacy (Article Referred By Lori Ramos)
The Department of Justice just proved my point.
Last week a supermarket pharmacy chain — Ahold Delhaize, the parent of Giant, Stop & Shop, Hannaford, and Food Lion — agreed to pay $40 million to settle False Claims Act allegations. The charge: they reported inflated “usual and customary” prices to Medicare Part D, Medicaid, and TRICARE, and in doing so made the government overpay on prescription after prescription. $32.9 million of that goes back to the feds, the rest to state Medicaid programs.
Stay with me, because this sounds backwards until you understand the machinery.
“Usual and customary” is just insurance jargon for your normal, everyday cash price — what a walk-in pays with no card, no plan, no middleman. That’s the same price I’ve been talking about for days. And here’s the part nobody outside the counter understands: if you accept insurance, that price MUST be high. It’s not greed. It’s survival.
Insurers reimburse pharmacies at the LOWER of two numbers — your usual and customary, or their contract rate. So the second you post honest, low, transparent prices, you’ve capped your own ceiling. Every claim defaults to your low number. Meanwhile the reimbursement model itself is garbage: pharmacies eat zero-dollar and below-cost reimbursements every single day. The only way you stay open is the occasional script that pays well enough to cover the pile of losses. List your real prices and you kill the high payers — but you’re still contractually bound to absorb the losses. So transparency, under an insurance contract, means you ONLY take losses.
That’s why discount cards exist. They’re a separate program, not your U&C — a workaround. The catch is they charge the pharmacy fees that wipe out most of whatever profit was left. Which brings us right back to this case.
Ahold did exactly what Walgreens and Kroger tried: list a high U&C for insurance, then run a separate “prescription savings program” with the real, lower prices on the side. DOJ’s position is simple — that savings-program price WAS the usual and customary, and burying it is fraud. Walgreens paid $100 million. Kroger settled for $17 million. It’s a pattern, and everyone who tries it gets shut down.
Here’s the kicker. This was a whistleblower case. A single pharmacist filed under the False Claims Act’s qui tam provision — a Civil-War-era law that lets insiders sue on the government’s behalf and keep a share of the recovery — and walked away with $6,083,587. So if you work at Amazon Pharmacy, you may want to take a hard look at that U&C.
This is the whole reason we fired insurance. We don’t accept it. We aren’t bound by anyone’s contract rate, we don’t report a U&C ceiling to a PBM, and we don’t bleed our prices through discount-card fees. It’s the only honest way left to price a prescription lower than the ridiculous insurance prices.
Affordable Cash-Pay Compounding Pharmacy | Forest Park Pharmacy Fort Worth
