This article is courtesy of guest writer Lisa Savage, MD.
Who hasn’t experienced sticker shock at the pharmacy?
The cost of medications, including hormone replacement therapy (HRT), can seem shocking, indeed. Why does this stuff cost so much? How can medications that have been around for a long time and are not made of gold dust keep going up in price? Why can the price for the exact same item vary wildly from one patient to the next? What is the actual “price” compared to what your insurance requires you to pay?
These are many of the questions that both patients and physicians (who are patients themselves from time to time) ask about the cost of medications. It is so frustrating for us doctors and nurses to recommend a product we know will work, that has a proven track record, and with which we have had long experience turn out to be unavailable to the patient because of cost. Insurance companies, PBM’s (pharmacy benefit managers), pharmacies and consumers are all caught in the web of inconsistency and variability. Pre-authorizations, third-party requirements, formularies…wouldn’t it be nice if buying your medications was as easy as buying anything else?
Take heart! There are some things you can do to better understand your options and find a product that will work for you without breaking the bank:
Get to know your insurance coverage if you have it. Most of us get the benefits brochure and stuff it in a drawer or never open the attachment. Instead, read all about it. Ask your broker or HR manager, call the 800 number on the back of the card, or consult the insurance company website if you have questions about what your plan covers. Does it include pharmacy benefits? Not all plans do. Do you have to use certain pharmacies to use the benefit? Sometimes this is the case.
Being familiar with what coverage you have helps you know what to expect and be able to actively manage your costs.
Unless your doctor feels strongly about a branded product or there isn’t a generic option for what you need, generic equivalents are the way to go. Generic formulations are allowed to vary by up to 20 percent on dosage compared to the original/brand-name product, but for most meds, this does not impact the effectiveness.
There are some cases where the generic product isn’t as well tolerated by an individual or conveys some different side effects, but unless this is the case, you will usually save quite a bit by using a generic.
Did you know that the out-of-pocket price, the one for uninsured patients, might be lower than what your insurance company asks you to pay? Ask, ask, ask. The pharmacist might or might not volunteer this information. A friend of mine found out her blood pressure medication is the same price for a 90 day supply without insurance as her “insured” price for 30 days.
Biggest takeaway here: Don’t assume that what your insurance company asks you to pay is the lowest price. Again, there are lots of entities hovering about the cash register, like ghosts in the background with their hands out.
If you are paying entirely out-of-pocket, the price of a medication can vary substantially between pharmacies. In my private practice, we created a spreadsheet of what local pharmacies charge for my commonly prescribed hormone therapy products and birth control pills. It was downright amazing what the differences were. Chain drug stores were the highest, sometimes double what others charged. In our market, Costco was usually lowest, followed by a Texas-based grocery store, followed by the others.
Check your own market. Call around, from membership warehouses to Mom & Pops. Do your research before opening your wallet.
Your insurance company may offer a much better price if you agree to use their mail-order pharmacy option. Or, you might find an online pharmacy that has better prices than your local brick and mortar stores. Be sure the online pharmacy is reputable; it should require you to submit a physician’s prescription.
One caveat with mail order is that many medications are temperature sensitive. I am unable to use a mail-order option here in Texas July-September, when our outside mailbox is subject to temperatures above 100 for days on end. I had to convince my insurer to allow the better price at a local place. It’s worth asking if you live in a place where temperature extremes at either end might bake or freeze your medication.
Consult your insurance company’s “Formulary.” This is a list of medications and how they are covered. The Formulary details for your particular plan may be different from the ones associated with other plans from the same carrier. It’s all about what coverage options your employer negotiated to buy on your behalf, as well as what choice you made when you enrolled.
One Humana plan is not the same as another. Your BCBS plan will be different from your friend’s unless you work at the same place and both chose the same option.
If you can have the Formulary for your plan available at your doctor’s appointment, it helps all of us be efficient with time and energy. That way we won’t prescribe something that is not covered or is stratospherically priced. Formularies frequently list products by “Tiers” of cost, so that Tier 1 is lowest, Tier 4 highest and so forth. Get familiar with how to read the Formulary and make it available at your appointment.
Sometimes manufacturers’ coupons are available, or you can compare prices and print a coupon from sites such as GoodRx. GoodRx makes money from the stores whose coupons appear as well as website ads; there is always a money trail and no such thing as no strings attached. But, a better deal is a better deal and online coupons can sometimes get you the best price. I always wonder why the price isn’t just lowered and consistent for everyone so that no middle steps (log on, find the coupon, print coupon, take coupon) are needed.
This type of account lets you set aside pre-tax money to cover a wide variety of medical needs, including medications. If you have to spend much on medications, at least there is the advantage of having pre-tax funds available.
Hopefully, all these tips will help you afford your medication. “Affordability” is subjective, though, so do think about the cost of HRT and other medications relative to discretionary things you readily pay for. If your daily coffee run sets you back a few dollars, then that amount of money per day for something that has a positive effect on your health is worth as much.
Put it in perspective, but don’t hesitate to say no to purchasing medication that seems exorbitantly priced. I tell my patients who experience sticker shock at the pharmacy “don’t buy it!” because lower-cost alternatives can almost always be found and feeling good shouldn’t break the bank. Your doctor can consider what is available to you and come up with products that will benefit both your physical and financial health!
Have you found ways to save money — safely! — on prescriptions? Let us know how you’ve handled it in the Gennev Community forums!
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