Nearly 10% of U.S. health care spending is for prescription drugs, totaling $370 billion in 2019. Remarkably, only half of that amount comes from insurance companies and the government; the rest is paid out-of-pocket by patients. On average, each American adult fills 17 prescriptions a year; the number doubles for those 65 and older.
Paying for prescription drugs can place a substantial financial burden on patients and families. According to a report from Georgetown University, 40% of patients admitted to not filling prescriptions because of the cost, or cutting their spending on food, heat and other necessities so that they can afford their meds.
Attempting to save money by skipping or taking less than the prescribed amount of medication is a bad idea. Patients have died from rationing to stretch out their supply of insulin or anti-epileptics. There are ways to make prescription medications more affordable that don’t involve endangering yourself.
When a new drug is approved by the FDA, the pharmaceutical company that developed and patented the drug is granted exclusive rights so they can recuperate research costs. After the patent expires (usually five to ten years later), other companies are allowed to make and sell generic formulations that contain the same active ingredient at a fraction of the price of the brand name drug. Ask your doctor or pharmacist if a generic equivalent is available.
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Check your insurance formulary
Most of the time, multiple drugs can treat the same disease, but one is preferred by the insurance because of their contracts with pharmaceutical companies. The insurance formulary — or the list of covered medications — is often divided into tiers, with the cheaper, more common, older and generic meds in the bottom layer and the more expensive, specialized, newer and branded meds at the top.
The higher tier meds will cost you more in copay and coinsurance. First make sure your drug is on formulary. Then note the tier of coverage and ask your doctor if there’s a similar option in the lower tiers.
If you must take a specific brand name drug not on the formulary because generics are unavailable or ineffective, you can petition to get coverage. The insurance company may require you to try (and fail) one or more similar drugs from their preferred list before agreeing to pay for the one you need.
If you have the choice (e.g. on Medicare Part D or the Marketplace, less likely for employer-sponsored insurance), pick the plan that has better coverage for your medications. Review your Insurance plan annually to check for changes.
Buy in bulk
Save on copays with a prescription for a 90-day supply. Mail-order pharmacies are often well-suited for this economical approach. Of course, this only applies to medications you take long term at a stable dose. Some doctors are also willing to write for double the dosage so you don’t have to fill the prescription as frequently, but you have to be responsible and organized enough to operate a pill splitter, and your drug can’t be an extended-release formulation or have specialized coatings.
Retail prices of drugs can vary widely depending on how pharmacies source their inventory. Big box chains (e.g. Walmart) and wholesale clubs (e.g. Costco) may have deals as low as $4 per prescription for generics. Call the pharmacy and ask what your out-of-pocket cost will be. Or type the name of your medication into Goodrx.com or Werx.org to compare prices.
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Uninsured patients and those needing medications not covered by insurance can apply for income-based assistance. Commercially insured patients can get a discount from pharmaceutical companies to decrease their copay. You can find resources on patient assistance programs through the government, nonprofit groups (e.g. Needymeds.org, Medicineassistancetool.org), disease-specific organizations (e.g. Epilepsy Foundation), and the manufacturer of your medication. The social worker at your doctor’s clinic can also help you navigate the application process.
Remember, the money you spend on prescription medications is tax-deductible (if the total amount of your unreimbursed medical expenses exceeds 7.5% of your adjusted gross income), so the tax season is another way to defray some of the cost.
When it comes to drugs, let’s be informed patients and discerning shoppers.
Qing Yang and Kevin Parker are a married couple and live in Springfield. Dr. Yang received her medical degree from Yale University School of Medicine and completed residency training at Massachusetts General Hospital. She is an anesthesiologist at HSHS Medical Group. Parker has helped formulate and administer public policy at various city and state governments around the country. He is formerly the group chief information officer for education with the Illinois Department of Innovation and Technology. This column is not intended to substitute for professional medical advice, diagnosis or treatment. The opinions are those of the writers and do not represent the views of their employers.