A doctor writes prescription, pharmacist fills prescription, insurance covers prescription. Simple, right? But that’s not the way it works anymore.
Some changes are good. Gone are the cryptic abbreviations and illegible handwriting — replaced by computer printed scripts, or better yet scripts magically transmitted via the ether. But along with fewer errors there’s even less transparency on pricing and coverage. Patients, who haven’t been to pharmacy school and couldn’t possibly decode the pages of exclusions and conditions in their insurance contract, get hosed. And doctors and pharmacists get blamed.
Remember this, if nothing else: it’s all gamed by the payer. Insurance company tricks are there to prevent them from spending money on your health care, while making your doctor and pharmacist look bad. Insurance companies are often abetted by pharmacy benefit managers (PBMs) – middlemen who skim even more health care dollars off the top, adding another layer of screwage.
But you can fight back. Here are some tips to help you get the medications you need, affordably.
Ask for generics (from your doctor and pharmacist). There are often generics available, though these days they’re not always cheaper than the brands. Ask anyway. Remember that newer, brand-only drugs are not more likely to be better or safer. Go with an older, established medication if you can.
Don’t assume your “insurance price” is the best price. You might think your insurance-negotiated rate is better than what you can get without insurance. That’s not necessarily so. Those PBMs mark up everything, and often drive the price of very inexpensive drugs higher for those with insurance. Ask for the retail price to compare. And check out pricing sites, too.
Visit NeedyMeds.org for drug-discount programs and other information. This is a great non-profit, non-commercial site that pulls together just about all of the information you need to save money on prescriptions. There’s a price look-up, lists of industry- and private-sponsored assistance programs, and tons more.
Try out other “pricing sites” to help compare. Two simple ones that work well are Goodrx.com and WellRx.com. They don’t have the depth of info that NeedyMeds offers, but they’re simple to use to find prices in your area. You’ll enter the name of your medication and your zip code, and get back the price (to the penny) available at local chains. This assumes you don’t use your insurance – so keep in mind buying medications this way won’t count against your deductible.
Look into “90 day” supplies of medications. If you’re on a stable dose, your doctor may be happy to write for 90 days instead of 30. That often saves $$. But you won’t be able to refill your next supply until that 90 days is almost up, so pay attention to the calendar. If your doctor sends the prescription in too soon, the pharmacist will hold it until your insurance company deems it time for you to be able to refill it. Not doctor’s fault, not pharmacist’s fault.
Don’t assume mail-order pharmacies are cheaper than filling locally. This happened to me – the Aetna mail order 90 day supply price was twice what it cost to fill the same medication for 90 days at my local pharmacy. Unexpected. But I’ll take the less-expensive, less-hassle option of a local pharmacy for sure.
Not-in-stock doesn’t mean never-in-stock. If your medication is out of stock at your favorite pharmacy, they can usually order it in just a few days – just ask them, if you’re not in a huge hurry to get the medications. If you are in a hurry, call around to different chains (not just different locations of the same chain, which probably use the same warehouse to resupply them shelves.)
Avoid “prior authorization” medications when possible. A prior authorization is a nightmare, designed to prevent you from getting medicine while making it look like your doctor’s fault. “Just tell them to do a prior authorization,” you’ll be told – but doing a prior authorization typically takes a tremendous amount of time and frustration, and unless you’ve met the “secret criteria” it’s not going to work.
If you do need a prior authorization, figure out the “secret rules” first. As with any game, you won’t win if you don’t know the rules. If your insurance insists on a prior authorization, call them and get them to tell you exactly what is needed to happen for the prior authorization to be approved. Do you need to try one or more medications first? Which medications? What are the criteria that they use to make their determination of coverage? If you can find that out and tell your doctor, it will save everyone a lot of hassle – and you might just get your medications covered.
Consider OTCs over prescriptions. There’s a mystique to prescription medications, and that makes it seem like they’re more powerful or more-likely to work. That’s just not true. For conditions like allergies and acne, OTC medications or combinations of OTCs and prescriptions are often just as effective, safer, and cheaper than prescriptions.
The deck may seem stacked against you – the insurance company has the resources, and they make the rules. But you’ve got your doctors, nurses, and pharmacists on your side. Work together to get the medications you need at a price you can afford.
Roy Benaroch is a pediatrician who blogs at the Pediatric Insider. He is also the author of A Guide to Getting the Best Health Care for Your Child and the creator of The Great Courses’ Medical School for Everyone: Grand Rounds Cases.
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