Ask Emily is a biweekly column by Emily Bazar of the CHCF Center for Health Reporting, answering consumers’ questions about California’s new medical world. Read her columns at sacbee.com/ask-emily.
If you haven’t experienced it yourself, you’ve no doubt heard about the outrageous – and rapidly growing – prices of certain prescription medications.
The average price of about one year of cancer-drug therapy has skyrocketed from $10,000 (or less) before 2000 to more than $100,000 by 2012, according to a recent Mayo Clinic study.
The new hepatitis C drug Sovaldi comes at a retail price tag of $84,000 for a 12-week course.
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Prices are even spiking for some generics that have been around for years. Take the cost of the commonly used antibiotic doxycycline, which jumped from $20 for 500 pills in October 2013 to $1,849 in April 2014, according to AARP.
The unaffordability of drugs is a real and growing threat, even for people with health insurance.
Today I’m going to offer some tips on how to save money on your prescription drugs, whether you’re insured or not.
Q: I was recently diagnosed with cancer and had my first round of chemo. The nurse gave me a prescription for a generic anti-nausea medication. When my wife took it to the drugstore, she was quoted a price of $900 for a 30-day supply. How is that possible?
A: I wish I could answer the question from Jim Buchanan of Hemet, but I don’t know why a generic anti-nausea drug would cost $900 out of pocket, even with his insurance applied to the prescription.
I can say that his wife, Susan Buchanan, did the right thing when she didn’t take $900 for an answer. Though “totally in shock” from the quoted price, she asked what the cost of the prescription would be without applying insurance.
Counterintuitive? Yes. Confusing? Definitely.
“In some cases, people may be better off not using their insurance,” says Betsy Imholz, special projects director at Consumers Union.
Lesson 1: Shop smart.
When you get your prescription, call multiple pharmacies and negotiate, even for generics. Neighborhood pharmacies may have more autonomy to lower prices than chain stores, Imholz says.
If you don’t have insurance, however, Costco has the lowest price of chain stores on average, she says. You don’t have to be a member to use its pharmacy.
Finally, ask your doctor to write a prescription for a 90-day supply of drugs instead of 30 days. “You’ll be avoiding copays and trips to the pharmacy,” she says.
Lesson 2: Appeal for coverage.
Let’s say your doctor wants you to take a medication that’s not on your plan’s formulary and you’re faced with paying full cost.
Before you empty your pockets, file an appeal with your insurer, which in most cases must cover medically necessary drugs that aren’t on their formularies – if your condition warrants their use.
If your health plan rejects your appeal, contact your regulator and request an independent medical review, which is free. The health plan’s denial letter will specify your regulator, or try the state Department of Managed Health Care (888-466-2219 or www.HealthHelp.ca.gov) or the state Department of Insurance (800-927-4357 or www.Insurance.ca.gov).
You’ll need to work with your doctor through this process to help you prove medical necessity.
Lesson 3: Look for financial assistance.
There are a slew of programs offered by drug companies and foundations, and many websites that help you search for them. One is NeedyMeds (www.NeedyMeds.org), a national nonprofit that helps connect people with assistance.
“Pharmaceutical companies give away billions of dollars in drugs every year to people in need,” says NeedyMeds President Richard Sagall.
Financial help from pharmaceutical companies is generally for brand-name drugs that don’t have generic equivalents. These programs have eligibility requirements based on four categories, Sagall says:
▪ Citizenship and immigration status.
▪ Some will only help people who are uninsured or have no drug coverage.
▪ Income. Many have relatively generous thresholds that include middle-class families.
▪ Some are disease- or diagnosis-specific.
All require some input from the doctor who prescribed the medication, Sagall says.
If you have drug coverage but can’t afford your copay, there are programs that may help with that, too.
Other helpful websites for financial assistance include the Partnership for Prescription Assistance (www.pparx.org); Patient Services Inc. (www.PatientServicesInc.org); and the Patient Advocate Foundation’s National Financial Resource Directory (www.PatientAdvocate.org).
Lesson 4: Use prescription discount cards and programs.
There are two types of drug discount cards. The first comes from pharmaceutical companies and generally offers discounts for a specific drug, Sagall says.
The other discounts multiple drugs and is offered by AARP, Costco, NeedyMeds and others. However, “you cannot use these in conjunction with insurance or state-federal programs such as Medicare,” he says.
But don’t forget the Buchanans of Hemet, who got a better deal without their insurance.
Lesson 5: Choose insurance with drug coverage you need.
One of the best ways to limit your out-of-pocket costs is to choose the best plan for your situation. You’ll have a chance to do that in your next open-enrollment period, which is fast approaching for most people.
If you have a chronic condition or take a lot of medications, try to avoid high-deductible plans, which include the “bronze” level plans sold by Covered California.
“If you have to pay a little higher premium but have lower out-of-pocket costs, that’s a better choice,” says Liz Helms, president/CEO of the California Chronic Care Coalition.
Questions for Emily: AskEmily@usc.edu
The CHCF Center for Health Reporting partners with news organizations to cover California health policy. Located at the USC Annenberg School for Communication and Journalism, it is funded by the nonpartisan California HealthCare Foundation.