I recently heard from a woman whose ophthalmologist prescribed a drug for her to clear up an eye infection. When the pharmacist told her that the 10-day supply cost $400 and her drug plan did not cover it, she decided not to fill the prescription. Fortunately, she then called her doctor, who prescribed another drug. It cost her $10 out-of-pocket and worked fine.
This woman’s experience just goes to show that even if you have prescription drug insurance through a Medicare Part D plan, a Medicare Advantage plan or a plan provided by your employer or purchased on your own, the out-of-pocket costs for many drugs can be overwhelming. On top of that, insurance companies that provide these plans are notorious for changing the terms of coverage even while your plan is in effect—removing a drug from their list of covered medications, for example. But there are ways that you can protect yourself. Here’s how to get the drugs you need at a price you can afford…
- Keep up to date. If you have prescription drug insurance, check the insurer’s list of covered drugs (it’s called the formulary) at least once every three months. This helps you stay ahead of the game if a notification from the insurer (see below) is ill-timed based on your schedule for refilling a prescription. Find out if the medications you take are still covered and if there are any changes in co-pays for those drugs. It’s easy to access the list via your plan’s website, but it’s smart to call, since websites are often outdated. If your doctor prescribes a new drug: Call your plan before filling the prescription to see if the drug is on the formulary. If the drug is not covered, ask your doctor if he/she can prescribe an acceptable alternative drug, such as a generic that is on your formulary.
- Get help from your doctor. If a drug you are taking is removed from the formulary while you are covered by the plan, the insurer must notify you in writing about the change. You and your doctor have three possible ways to respond. First, your doctor may prescribe another drug that’s already on the formulary. Second, your doctor may put you on “step therapy”—that is, a similar drug on the formulary is tried, but you can return to the original drug if the alternative medication does not work. Or third, your doctor can file an exception with the insurer, explaining that only the prescribed drug can effectively treat your condition. If the exception is granted (the answer usually comes within a few days), the plan will continue to cover the drug.
- Look for free money. Some of the newer “wonder” drugs are mind-bogglingly expensive. For example, the hepatitis C drug Sovaldi can cost $80,000 or more for a 12-week course of treatment. Even if your insurance covers it, co-payments and deductibles could easily reach $5,000 or more. But there is help. Most pharmaceutical companies have patient-assistance programs for many of their costlier drugs. In most cases, the drugs are provided at no charge or low cost to people who don’t have drug coverage and meet the program’s qualifications—typically based on income levels and/or liquid assets. Most pharmaceutical companies also offer assistance to people who have drug coverage but are unable to afford the co-payments and deductibles. My advice: To check out patient-assistance programs for any drug, go to RxAssist.org or Medicare.gov/pharmaceutical-assistance-program. This step could save you hundreds or even thousands of dollars!