Imagine me, a nurse advocate, getting a text from my pharmacy that the recent medication my doctor prescribed was going to have a $2,654.88 cost to me! This medication is not new or innovative by any means. To say the least, I was horrified and then I was angry and made a note to myself that I would not be paying that amount......
You Need To Know All of This!
By way of learning for my readers, I will outline the steps I took and where it all landed.
Checked with my physician and reputable medical online sites to see if there were cheaper alternatives, including a generic version of this drug.
I called my insurance company to obtain the coverage and formulary tier level of this drug.
I called the manufacturer of the medication to learn if there were any assistance and/or savings cards available. Yeah, there was a savings card with significant savings but costs were still very high.
I checked with all the sites I recommend to my clients, such as Needy Meds, GoodRx/Kroger Savings Club, RetailMeNot, OneRx, and ScriptSave.
Shopped around
Checked with local supermarket such as Shoprite as their costs can be lower
Checked Big Box stores such as Costco and Sam’s Club (oftentimes you don't have to be a member to use their pharmacy)
Compared the CVS, Walgreens, and Rite Aid costs
Called my insurance company to get a list of all the pharmacies it covers and their costs. Asked the pharmacy to send my physician a request to change the tier of the drug from Tier 2 to Tier 1, the cheapest level. More on this later.
Learned that the manufacturer savings card allotted $1,250 for the first prescription and $150 per every script after that until the year was complete and the reimbursement amounts were reset.
Researched the possibility of comparing prices of Canadian online pharmacies. More on this later too!
A Very Complex and Confusing System
We all need to know what Benefit Pharmacy Managers (BPM) are. The manufacturer of the drug sets the prices. Benefit Pharmacy Managers are middlemen, between the drug manufacturer and the pharmacy, such as Express Scripts. They negotiate the prices with the pharmacy. Some pharmacies deal with many BPM’s and each have a different price for the same drug. What a system!
Due to these complexities, insurers can wind up charging consumers more for the drug than a retail price. We have frequently received cheaper prices on drugs for our clients when we ask what the retail or cash price is for the drug.
In October 2018, President Trump signed two bills that overturned rules that prevent pharmacists from telling their customers when they’d be better off paying cash than using their insurance plan. You still need to ask the right questions as the pharmacist is not obligated to tell you, they have just had the “gag order” lifted so they can tell you if you ask.
Do Your Research
Do your research before you select the pharmacy to fill your medication. If need be, you can transfer your prescription to another pharmacy. If you find a cheaper price on an app you can show the pharmacist the app, which has a code number that will provide you the discount. Also, ask your pharmacist the retail price of the drug.
Although we do not recommend this approach due to potential regulatory and quality issues, be very careful if it is suggested you seek your medications from a Canadian online pharmacy. You need to be able to determine if the pharmacy is legitimate. Check the National Association of Pharmacy Regulatory Authorities (NAPRA) website https://napra.ca/online-pharmacies for more information and the following site for checking legitimacy. https://www.legitscript.com/.
It’s A New Year Be Informed and Educated
As we head into the new year there is information you should check on and verify:
Look up your new plan’s formulary (list of prescription drugs covered by your drug plan). You should be able to find the formulary on your insurance online portal. You can also call or chat with your insurance company to check on this.
Know what tier your drug is on the formulary
The tiers determine the costs of the drugs.
The tiers are determined by:
Cost of the drug
Cost of the drug and how it compares to other drugs for the same treatment
Drug availability
Clinical effectiveness and connection to standard of care
Other cost factors, including delivery and storage.
Tier 1 - Offer lowest co-payment and are often generic version of brand name drugs
Tier 2 - Offer medium co-payment and are often brand name drugs that are usually more affordable
Tier 3 - These drugs have the highest co-payment and are often brand-name drugs that have a generic version available
Tier 4 - These drugs are considered specialty drugs and are typically used to cover serious illness.
If your medication is not on your formulary, check with your physician for an alternative. If your drug is very expensive, have a conversation with your physician and see if there are less expensive alternatives like a generic or a lower-tiered medication.
Request medication refills early, in case you need prior authorization.
Check on getting a 90-day supply vs a 30-day supply.
Investigate all of the cost-saving tips noted in this article to make sure you're getting the best drug prices this year.
Medicare recipients can go to https://bit.ly/3niywFf to check on their drugs and what plan would be best.
Maximize your insurance benefits
Wellness and vaccine benefits – many plans provide free vaccines and wellness exams. Know what your plan offers.
Medication Management Services – Many Medicare Part D and some commercial insurances cover services like medication review, provided by your pharmacy. This is a free service and worth the review.
Minimize Out of Pocket Costs – in high deductible plans, certain over the counter (OTC) items may be purchased using your health savings account (HSA). Check with your insurance company on this.
In summary, we all need to know what our options are for medication pricing and insurance coverage. It is important to be educated and it helps to have a professional insurance advocate provide advice and counsel. My story ended with my first script costing $5.00, that’s down from $2,654.88, however, my next script will not be $5.00 until the annual clock resets and by then I hope to not have to take this drug.