According to data from an international health policy survey, in 2016 approximately 45 million Americans reported not filling prescription medications due to concerns regarding the cost. In addition, in 2016 Americans are estimated to have spent $477 billion on retail prescription drugs, accounting for approximately 17% of total personal health expenditures (including physician services, hospital care, and other health-related costs). If the cost of some of your medications has been a concern for you, you are certainly not alone.
Why are my prescription medications so expensive?
First, I will not bore you with detailed explanations regarding the amount of money that drug manufacturers spend between research and development of a potential new drug, and their respective clinical trials with hopes that maybe it will approved by the Food and Drug Administration to be marketed for use. Instead, I am going to focus specifically how you may personally experience sticker shock when being informed of the cost of your medication(s). Here are some very common reasons why you may experience this:
1. Your insurance plan may have a high deductible. Many insurance plans include a deductible, which translates to you being required to cover a certain amount of out-of-pocket costs before your plan covers the majority of the expenses. For example, some plans may require a policy holder to cover the first $500 to $3,000 of their health-related expenses before seeing their medications covered with a set copay.
2. Medicare D prescription plans and the “Donut Hole.” This is a term used to refer to a gap in coverage once a patient has reach a set combined prescription cost for the year, therefore making the patient responsible for covering a greater percentage of the cost of medications. For more information about the “Donut Hole” see our article from November 2018!
3. Formularies set by your insurance. In simple terms, a formulary is a list of medications recognized by an insurance plan, and designates these medications as being “preferred”, “non-preferred formulary”, and “non-formulary.” Medications designated as preferred generally have lower copays associated with them, while medications designated as non-preferred formulary are usually covered by the insurance, but often have a higher copay. Non-formulary medications often may not be covered at all by the insurance plan.
4. Some medications require prior authorization to be covered. In these cases, a prescribed medication may not be immediately covered by your insurance, but may eventually be covered if prior authorization is granted. This process requires the prescriber to forward additional information to your insurance plan to explain why this medication is necessary for your treatment. Your insurance would then review this request and determine if the medication in question would be covered, and if so, for how long and at what copay.
How can I learn about ways to lower the cost of my medications?
For this, I cannot overstate the importance of knowing your medications and their respective roles in your therapy. At times, it can be more difficult for a pharmacist to recommend an alternative medication to a prescriber without knowing what other medications you are taking, what medications you have previously used, and what history of drug allergies/sensitivities you are aware of. A great way to keep you and your pharmacist on the same page is to have your pharmacist conduct a Comprehensive Medication Review with you. Not only does this service increase your knowledge about your medications, but one of the additional perks of having this done is that it allows the pharmacist to potentially identify cost-saving opportunities for you. (Contact BetterMyMeds for more information about medication reviews or to schedule a consultation.) Here are some additional strategies to potentially reduce your costs:
Ask your pharmacist to communicate with your insurance to determine what alternatives may be covered, as well as to communicate with prescriber to offer suggestions. Sometimes finding a less-expensive option can be as simple as adjusting the dose of the same medication, or even which company’s brand of the drug is being used. Other times, there may be a similar drug that is preferred by the insurance plan’s formulary, or a generic available of a similar drug when only the brand name is available for the prescribed drug.
Multiple discount plans are available. This is generally more helpful to those who do not have good prescription coverage (or any at all). These discount plans (such as GoodRx) can generally be found on-line, and offer a discounted price on various medications. However, be aware that these discounts do not always apply evenly to all pharmacies.
Patient assistance plans available directly through manufacturer of the drug. Many of the companies who develop and market these medications offer patient assistance plans to help decrease the cost to those in need. Information regarding these assistance programs can generally be found on the websites of the manufacturers, along with application forms for the patient to complete (if required for certain assistance plans). Your pharmacist can help direct you to this information to see if you may be eligible to take advantage of these plans. Note: Often there are restrictions for many of these plans including the prohibition of using these plans if the patient is eligible for a government-funded insurance such as Medicaid or Medicare part D, or some assistance plans require that the medication initially be billed through the patient’s primary insurance plan and the assistance plan would then be billed as a secondary plan to hopefully reduce the final copay.
In some cases, if a patient is enrolled in a Medicare part D plan and can provide evidence of limited income, the pharmacist may be able to communicate with the insurance plan to see if the patient would qualify for a tier reduction of the drug, which generally reduces the cost to the patient. This usually requires the patient to submit an application form to the insurance plan along with proof of income.
What NOT to do with your medications to save money:
Do NOT choose to pass on having a prescription filled without consulting with your pharmacist. By far, the majority of physicians will not prescribe a medication to a patient if he/she did not believe that it will benefit your health. However, in some cases, the medication prescribed is extremely important. For example, some infections require an antibiotic that has certain coverage against the suspected bacteria (please keep in mind that not all antibiotics are equal regarding their efficacy against strains of bacteria). If the initially prescribed antibiotic is considered too expensive, ask your pharmacist to consult with the prescriber to determine if a less-expensive alternative is available without compromising efficacy of therapy, which can lead to further complications.
Do NOT skip doses of your medication, hoping to extend how long they last. While it is generally understood that taking your medications as directed benefits your health, did you know that missing as few as 1 or 2 doses can harm you? For example, with some blood pressure medications, missing 1 or 2 doses can lead to what is known as rebound-hypertension, which is an unsafe dramatic rise in your blood pressure, which can increase your risk for heart attack or stroke.
Do NOT keep using medications that have passed the expiration date. While using most medications after the expiration date likely will not harm you, there is a very good chance that you will not receive the full benefit of these medications as they may have lost some of their potency. A good example is with insulin vials or insulin pens. Different types of insulin should not be used after a certain amount of days from the first use, as there is evidence that the product may not have the full desired effect, which could compromise the control of your blood sugar levels.
Do NOT substitute natural, homeopathic products for prescription therapies without discussing with your pharmacist and physician!!! While some homeopathic products do have potential roles, they are generally not considered an ideal replacement for prescription therapy.
Finally, here is a link to an article that describes how 1 in 4 Americans have difficulty affording their medications (just to highlight that if cost is a barrier for you, you are not alone & we are willing to help you)!