Ways to cut drug costs when your health insurance changes
These changes will help, but high drug costs remain a big problem even though most Americans have health insurance. Three in 10 adults reported not taking medicine as prescribed at some point in the previous year because of the cost, according to a KFF survey in March 2022. This includes about 1 in 5 who said they had not filled a prescription because of its cost.
People also may have to reach deeper into their wallets because of changes to their insurance plans. For example, a drug might no longer be covered or might be covered less, says Stacie Dusetzina, a professor of health policy at Vanderbilt University School of Medicine in Nashville and an expert in health costs. When either happens, “you’ll be stuck with a higher bill,” she says.
Other causes of drug price sticker shock are high deductibles, expired discount coupons and more.
When you first see a price jump
If a drug you take suddenly becomes more expensive, make sure the new price is accurate. For example, if you’ve changed jobs, make sure the pharmacy has the right insurance information. Or it’s possible your pharmacy may have lost your details, says pharmacist Brandy Letson, co-owner of Cashiers Valley Pharmacy in Cashiers, N.C. In either case, the pharmacy “won’t locate your insurance coverage properly and you’ll get charged the full price,” she says.
Also confirm that the pharmacy has the right info about your drug, Letson says. “Sometimes doctors send prescriptions for a larger quantity of drug than you want, or at a higher dosage, which could raise the cost.” Price still high? The cause may be one of the situations detailed below. Check out our solutions for each.
Problem: Your insurer no longer covers your drug
Maybe you’ve changed jobs and the insurer doesn’t cover your drug. Or your insurer changed its formulary, the list of drugs it covers.
While the insurer must notify you of formulary changes, the alert can be easy to miss or hard to understand, says Stephen W. Schondelmeyer, a professor at the University of Minnesota and director of the Prime Institute, which researches economic and policy issues regarding pharmaceuticals.
The three big pharmacy benefits companies (which manage drug coverage for insurance companies) have dropped a record number of medications for 2023, according to an analysis by Adam Fein, an expert on drug pricing and founder of the Drug Channels Institute, an industry research firm.
Solution: File an appeal. If you have employer-provided or private insurance and you take a drug that works well, and changing to another poses a hazard to your health, ask your doctor and pharmacist to appeal for an exception with your insurer.
To file an appeal, you may need to provide records from your pharmacist in the package you submit. The Patient Advocate Foundation can help if you have a serious condition, such as cancer or rheumatoid arthritis. Call 800-532-5274 or go to PatientAdvocate.org.
If you have Medicare Part D and the denied drug isn’t in a specialty tier, you can apply for an exception by calling your plan. If approved, the exception usually runs out at the end of the calendar year. You can ask for an extension or apply again. If that’s denied, you can file for a “redetermination.” Your plan should explain how to do this. A standard redetermination takes up to a week to process; an expedited one, 72 hours.
Problem: Instead of a cheap co-pay, you now pay a percentage of the full drug cost
A formulary change can mean a drug that used to cost a fixed $10 or $15 co-pay now costs 20 percent, 30 percent or more of its full cost. This is called coinsurance, and you may be asked to pay it for more expensive brand-name medicines or high-cost generics, Schondelmeyer says. And because coinsurance is based on a drug’s full cost, if that increases, your out-of-pocket share will go up, too.
Solution: Consider applying for a manufacturer co-pay coupon. That could work if you have employer insurance and take a branded medication for which you pay coinsurance or a co-pay.
To find a co-pay program, ask your pharmacist, go to the drug manufacturer’s website or go to NeedyMeds.org, a nonprofit group that tracks drug discount programs.
Problem: Your drug company coupon no longer saves you much
Co-pay cards and other discount programs offered by branded drugmakers can be major cost-savers, but they’re not a forever fix, Dusetzina says. They may limit how many prescriptions you can fill in a year. Or there may also be a dollar limit to how much the manufacturer will cover, Dusetzina says.
Solution: Ask the manufacturer for other payment options or an exception. Some have leeway to cover your costs in the short term or until a new plan year begins, says Rich Sagall, president of NeedyMeds.
Other potential solutions: If you work for a self-insured employer, contact your HR department and appeal for a higher rate of reimbursement; or consider applying for a patient assistance program from the drug manufacturer by going to NeedyMeds.org and looking up your drug’s discount and assistance programs.
Problem: You must first meet a deductible
You’re probably familiar with paying deductibles for doctor visits. But you may have a separate deductible for prescription drugs, Dusetzina says. Or you may have to meet your plan’s full deductible before your plan’s drug coverage kicks in. In either case, the average deductible for an individual on an employer plan last year (including for drugs) was about $1,763, according to KFF, a nonprofit health research and policy group. For Medicare Part D plans, the maximum deductible in 2023 is $505.
Solution: Consider paying cash. Counterintuitively, some drugs can be more expensive when you use insurance to pay for them, Dusetzina says. And some, including hundreds of low-cost generics, can be inexpensive if you pay for them with cash.
For example, Walmart’s discount program offers a month’s supply of generic drugs for $4, or $10 for a 90-day supply. You can also find online discounts at HealthWarehouse.com, Costco.com and CostPlusDrugs.com. Your local independent pharmacy may also meet or beat a price you find online or at a big chain store.
Problem: You must try — and fail — on other drugs before the insurer will cover your med
Called step therapy, your insurer may ask you to try a lower-cost alternative medication before it covers a pricey, brand-name drug.
Solution: If you already know that other drugs don’t work as well for you, ask your doctor to apply for prior authorization and, if necessary, for the insurer to reconsider the decision. (If it does, you’ll be charged a co-pay or coinsurance. If not approved, you’ll be on the hook for the full amount.)
If that fails, ask your pharmacist to look for coupons or apply for a manufacturer’s patient assistance program. These programs were once reserved for low-income people, but many manufacturers have loosened their eligibility requirements and some have set income caps over $100,000.
More ways to save on your meds
Buy in bulk. If you’re positive you’ll be taking the same drug at the same dose for a while, you can save a lot by filling prescriptions for several months at a time.
Consider an online pharmacy subscription service if you take several generics. Two options: ScriptCo and GoodRx. At both, you pay an annual fee and get free or low-cost common generic meds, sometimes for just pennies per pill.
On Medicare Part D? See whether you qualify for “Extra Help” in 2024. A third of all enrollees in Medicare Part D get some sort of assistance, according to figures from KFF, and with the Inflation Reduction Act, up to 300,000 additional people will be eligible for the assistance. Find out whether you qualify at SSA.gov/extrahelp or call 800-772-1213.
Ask the drug company for a rebate. In addition to drug co-pay coupons and patient assistance programs, consider calling the drug manufacturer to see whether it’s willing to offer you a rebate. Some may do this if you ask, Sagall says.
Copyright 2023, Consumer Reports Inc.
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