It happens to all of us: Your doctor prescribes you a new prescription drug. Normally, doctors don’t really know the true cost of a medication at the pharmacy counter when they are in the office prescribing it.
Card in hand, you wait in line at the pharmacy counter and present the prescription. A few minutes later, a smiling pharmacy technician asks you for your information and your insurance card and next thing you know, the bill is a whopper! What do you do?
If you’re on Medicare, you have several options if you cannot afford a prescription that your doctor prescribes. The very first thing you should do is ask the pharmacy if your insurance actually covers the prescription in the first place! Ask why the cost is so high! Have a dialogue with the pharmacist or pharmacy technician. Often times, they’re very busy and won’t go that extra step in the first place. Sometimes the prescription isn’t covered for a reason that you can do something about!
If you have been given a brand name of a drug, its worth asking if there is a generic equivalent. Sometimes it’s a simple matter of calling the doctor to make the change. For example, the name brand is a 24-hour pill, but the generic needs to be taken 3 times a day. If the savings are astronomical it may be worth that bit of hassle.
Sometimes, your prescription needs what’s called prior authorization, or a medical review. This means that your doctor needs to speak to the insurance company and give them medical information about your condition to get your prescription approved. In this case, your prescription is just in a temporary limbo and still has a chance to be covered. The pharmacy may have just filled it for the cash price to find out if you wanted it immediately, wanted to pay for it, or needed to know how much it was in case the medical review was denied.
If the drug is not on the formulary, or list of drugs covered by your plan, then you have some options to consider. The first thing you should do at this point is contact your doctors office and inform them of this information. Often times, there is different medication that acts the same that is covered. It’s just a matter of the doctor sending the appropriate prescription to the pharmacy for you.
If the drug is on the formulary and you still cannot afford it, you still have options.
Depending on which state you live in, there are programs for elderly people to assist them with prescription drug costs. They are called State Pharmaceutical Assistants Programs (SPAPs) For example, in New York it is called Elderly Pharmaceutical Insurance Coverage (EPIC) and it works with Medicare to bring down the costs of drugs.
If you do not have a SPAP in your state and cannot afford your medications, you still have options!
Contact the pharmaceutical companies directly. Many of them have Patient Assistance Programs (PAPs) that qualify individuals based on income levels for free or lower cost medications. This is for name brand medications. You can search for all available PAPs by the drug name or the pharmaceutical company name at RxAssist.org/patients.
If you do not qualify for the patient prescription program through the pharmaceutical company, there’s another oft overlooked option.
There are pros and cons of skipping using your Medicare/medical insurance. On the one hand, if you don’t use your MAPD or PDP plan to fill a prescription, you won’t get “credit” through the four stages of Medicare Prescription Drug benefits. However, if your copay is too high, like during the coverage gap (aka donut hole), and you cannot afford your medication, ask the pharmacist to fill your prescription and use one of the many free discount cards that are available. You CANNOT use them with insurance.
We want to highlight this once again: doing this does not count your medication cost total toward getting out of the coverage gap (aka donut hole) nor does it help you meet your deductible if you have one. You will be no closer to catastrophic coverage by using a discount card or paying for your prescription. This is merely a way to possibly get a better discount on your prescription.
Currently, you pay a percentage of any brand name drug during the ‘donut hole’ coverage gap phase of coverage, some of the discount cards have great prices and can beat that cost. If know you aren’t going to reach catastrophic coverage during the year, ask the pharmacist if using a discount card instead of your insurance would help bring down the price. It might, it might not, but it cannot hurt to ask.
Where do you get these discount cards? Search for “Free Prescription Savings” online. GoodRx.com, HelpRx.com are two options, but we don’t endorse either. In fact, we don’t endorse anyone, or any company in particular. Do your own research. Remember each of these savings cards are free. Don’t pay for a savings card. They also give different offers, so go to the pharmacy armed with at least two cards to see what gives you the best discount.
You have options and questions that you can ask when it comes to high prescription prices. Sometimes nothing can be done, and you have to just contact your doctor and tell him that you cannot afford this prescription and ask if there’s something else you can take. It happens to all of us at one point or another.
There are often alternatives to the expensive medication when you ask. Pharmacists cannot change the prescription even if its from brand to generic without the doctor’s authorization so be prepared to wait for them to contact the office.
Make it a point to sign up for your state’s SPAP before you need it as it may have deductibles to meet before it kicks in to help you cover costs. Don’t forget to try SPAPs for any brand name prescriptions you may have that you cannot afford.
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Author Bio: Ben started Prepare for Medicare in 2014 to help people help people get objective answers to questions about Medicare. He’s held leadership roles at numerous Fortune 500 Medicare health insurers in product development, sales, marketing and strategy for over 20 years.