Most patients that need help with their prescription medications are actively on Medicare. This means that they are not able to participate in a lot of the programs that are currently advertised to help save on cost. There are some medications that are not covered by your insurance plan. The medications that are covered are called a formulary.
You should ask your pharmacist two main questions if a prescription is too costly.
Did my insurance cover any of the cost of this medication?
Does it need a prior authorization?
If your insurance covered a small portion of your medication costs, the main issue that I’ve seen is something called a deductible. Deductibles are not new to insurance, but it is new to the prescription coverage world. A deductible is a set amount of money that must be paid out by the patient before the insurance kicks in and covers more. I have seen deductibles range from about $200-$400, on average.
Unfortunately, there is no way around paying your deductible. The good news is that a deductible is typically only applied to brand name medications. There are some loopholes that may apply (leave a comment if you want to know more about that). Once the deductible is paid, the out of pocket expense for the patient is usually dramatically reduced and much more affordable.
The second part of this equation is what we call a prior authorization. That means the medication that your provider prescribed is covered, but under certain conditions. This needs to be completed by the provider or their staff. A patient can start the process by calling their insurance company and asking them to reach out to the doctor's office directly.
When a medication is “approved” it is only approved for a set number of days, typically 1 year. Some prior authorizations are easier than others. Some medications just need a diagnosis code, while others request a list of medications that have been tried and failed, with dates and reactions. Lastly, sometimes the insurance company just wanted the patient to try their preferred medication first.
Depending on what your insurance requires, will determine your next steps.
Join me next week when we go over a 3rd option… Medications that are covered, do not need a prior authorization, but are still too expensive.