“Prescription medications are one area where an informed, price-conscious consumer can actually save money if they try.” Elisabeth Russell, President, Patient Navigator

When choosing a health insurance plan, it’s just as important to make sure the medicines you take regularly are covered as it is to know that your doctor is covered.  Selecting the right prescription coverage for you and your family is important to maintaining and restoring your health while managing costs.

While most health insurance pays for prescription medicines, the rules for pharmacy benefits are often different than for other medical benefits. For example, your prescription claims may be handled by a pharmacy benefit manager, or PBM—not by your insurance company directly.

When making decisions about your health insurance, always look at the impact the decision may have on your access to the medicines that members of your family are currently taking.  When shopping for pharmacy benefits, make sure you understand how to file an appeal if your plan will not pay for medicine you need, how much refills will cost you and what choice of pharmacies you will have to fill prescriptions.

Step 1:  Find out if the health plan or pharmacy benefit manager covers the drugs you need.

If your plan offers prescription drug benefits, your insurer may control costs through a formulary, which is a list of drugs the company prefers you to use because they are less expensive.

Your co-pay will be lower if you purchase a drug on the insurance company’s formulary.

If you’re using a drug not on the preferred list, you may want to bring the formulary to your doctor’s office to see if you can substitute the drug you are taking with a less expensive, medically-equivalent drug on the formulary.

Note that formularies do change regularly.  Your insurer might add a new drug or stop covering a drug at any time.  You can usually check the formulary list on-line, or call the toll-free member services number on the back of your insurance card.

  • Generics: A less expensive alternative

If your doctor prescribes a medication not on the formulary under its brand name, you may still be able to get it inexpensively as a generic.  Generic drugs are exact chemical copies of brand name medications whose patents have expired.  Many plans will automatically fill the prescription with a generic unless your doctor specifies the name brand.  Don’t be fooled by slick pharmaceutical advertising on television.  There are many older and cheaper drugs that can treat your condition just as well.

  • Pharmacy networks and mail-order services

Some plans charge you less if you use a pharmacy in their pharmacy network, just as they charge you less if you see an in-network doctor.  If that’s the case, ask if your pharmacy is in the network before you fill the prescription. Otherwise, you may pay twice as much for the same drug.  The website of most large drug store chains usually list the insurance plans with which they participate.

Many plans now offer a mail-order option that lets you order as much as 90 days’ worth of the drugs you take. However you obtain the medication, ask your doctor to write the prescription for the maximum number of doses you can order for a single co-pay.  Your co-pay may be the same for both a 60- and 90-day supply.  It’s especially important to ask for the maximum prescription because some medical practices now charge patients to write out refill prescriptions.

Step 2:   Manage Your Medications and Keep Them Current.

It’s always best to ask your pharmacist how much a particular medication will cost you BEFORE the prescription is filled.  If you have a problem with your coverage, it can be resolved, or you can call your doctor regarding other choices before you are forced to pay a higher fee than necessary.

A personal medication record makes navigating your pharmacy benefit much easier, whether you’re choosing a new plan or working with one that you’ve used for years.  It will also help you partner with your doctor to talk about new treatment options, food and drug interactions.

Navigator Tip:

Our “My Patient Navigator Medical Planner” includes a section to keep track of your medications.

Navigator Tip:

The Medicare website includes a tool for senior to track their medications.  This is very useful as it can be updated, printed and brought to a doctor visit.  This tool also calculates which Part D Medicare Drug Benefit plan in your area would be most beneficial based on the medications you take.  Visit the My Medicare site to set up an account which will also track your Medicare claims.

Navigator Tip:

No matter what method you use, if you take medications for various conditions, make sure you keep an up-to-date list.  In an emergency, one of the first things doctors must know is what medications you take.

Step 3:   Help for the Uninsured.

There are pharmacy and medication assistance programs available for the uninsured.

  • Pharmaceutical assistance programs can provide help with prescription drugs.  The Partnership for Prescription Assistance (1-888-477-2669) can help find assistance from pharmaceutical companies as well as state programs that include assistance for the uninsured.  A physician or medical social worker can help you find out whether a specific drug might be available at a reduced cost.  Most pharmaceutical companies will have a section titled “patient assistance programs” on their website.
  • You can find co-pay relief programs for medicines to insured patient who financially and medically qualify.  See the detailed chart of programs at the Cancer Care website.
  • The Chronic Disease Fund (1- 877-968-7333) is a non-profit charitable organization that helps under-insured patients with chronic disease, cancers or life-altering conditions obtain the expensive medications they need.
  • NeedyMeds is a web-based information resource for people who need assistance paying for health care.  It has information on patient assistance programs that provide free of low-cost medicine to people who are uninsured or underinsured.   RxHope (732-507-7400) helps patients obtain free or low-cost prescription medications.
  • The CancerCare Co-Payment Assistance Foundation (1-866-552-6729) provides co-payment assistance for patients who have been prescribed chemotherapy but are unable to afford the out-of-pocket costs or co-payments required by their insurer or Medicaid.

For more information, please refer to the My Patient Navigator “Find Financial and Practical Assistance” roadmap.