Can’t Afford Your Prescription? How to Lower the Cost of Your Medication
You have a prescription. Your doctor wants you to take it. Then you get to the pharmacy and discover that the medication costs far more than you expected.
Sometimes it’s a high copay. Sometimes insurance refuses to cover the drug. Sometimes you haven’t met your deductible. Sometimes the medication isn’t on your plan’s formulary. And sometimes the cash price itself is simply unaffordable.
Whatever the reason, don’t assume the price you’re quoted at the pharmacy is the only price available or that abandoning the prescription is your only option.
Prescription drug pricing is complicated, but there are several different ways to investigate the cost and determine whether a less expensive path exists.
The first step is figuring out why the medication costs what it does for you.
Find out whether insurance is actually covering the medication
If you have prescription drug coverage, start with your health plan.
A high pharmacy price can mean very different things depending on how the claim was processed. The drug may be covered but subject to your deductible. It may be placed on an expensive formulary tier. It may require prior authorization or step therapy. Your plan may prefer a different medication. The pharmacy itself may be outside your plan’s preferred network.
Ask your insurer or pharmacy benefit administrator how the prescription was processed and what portion of the cost is your responsibility.
You want to know whether the medication is covered, what formulary tier it occupies, whether any utilization requirements apply, and whether using a different pharmacy would change the price.
Until you know why the price is high, you don’t know which problem you’re trying to solve.
Check your plan’s formulary
A formulary is the list of medications covered by a health plan and the conditions under which they are covered.
Many formularies divide medications into tiers. Drugs on lower tiers generally cost patients less, while specialty or non-preferred medications can carry substantially higher out-of-pocket costs.
If your prescription is expensive because of its formulary placement, find out whether your plan covers another medication used for the same condition at a lower cost.
Do not switch medications on your own.
Ask your doctor or other prescribing clinician whether a covered alternative would be medically appropriate for you.
There may be an important clinical reason you were prescribed a particular medication. If so, that information may become relevant when requesting an exception or appealing an insurance decision.
Ask whether a generic or biosimilar is appropriate
For some medications, a lower-cost generic equivalent may be available.
Generic drugs contain the same active ingredient as their brand-name counterparts and must meet standards established by the U.S. Food and Drug Administration. They are often substantially less expensive.
For certain biologic medications, an FDA-approved biosimilar may also be available. Biosimilars are highly similar to an FDA-approved biologic medication and have no clinically meaningful differences in safety, purity, and potency from the reference product.
Availability and substitution rules vary, and not every medication has a generic or biosimilar alternative.
Ask your prescriber or pharmacist whether one exists and whether it is appropriate for your treatment.
Compare the insurance price with the cash price
This part of prescription pricing can feel counterintuitive.
Using insurance is not always the least expensive way to purchase a medication.
Ask the pharmacist what the prescription would cost if you paid cash rather than processing it through your insurance. You can also compare prices among pharmacies and legitimate prescription discount services.
If you pay outside your insurance benefit, however, the purchase may not count toward your deductible or annual out-of-pocket maximum.
That tradeoff matters.
A $20 cash price may look much better than an $80 insurance price today, but the effect on your annual healthcare spending depends on your plan and how much medical care you expect to use.
Compare the options rather than assuming either insurance or cash is automatically better.
Prices can vary between pharmacies
The price quoted by one pharmacy is not necessarily the price you will find everywhere.
Your insurance plan may have preferred pharmacies where your copayment or coinsurance is lower. Mail-order or specialty pharmacy requirements may also affect coverage for certain drugs.
Cash prices can vary as well.
Before transferring a prescription, confirm that the pharmacy can dispense the medication and determine the actual price that would apply to you.
For specialty drugs, distribution may be restricted to particular pharmacies, so comparison shopping may be more limited.
Ask your prescriber about the cost
Patients sometimes leave the pharmacy without their medication because they assume the prescribing office cannot do anything about the price.
Tell the prescriber that the medication is unaffordable.
Be specific.
Explain what the pharmacy quoted you and what your insurer said about coverage.
The prescriber may know of an appropriate lower-cost medication. The office may also be able to provide documentation required for prior authorization, request a formulary exception, or explain why a preferred alternative is not appropriate for your condition.
Cost is part of whether a treatment is realistically accessible. Your healthcare team needs to know when price is preventing you from following the treatment plan.
Find out whether prior authorization is the problem
Some medications are covered only after the insurer approves a prior authorization request.
The insurer may require clinical documentation showing that you meet its coverage criteria. It may also require you to try another medication first.
If the pharmacy tells you the drug “isn’t covered,” clarify whether that means the medication is completely excluded from your plan or simply requires additional approval.
Those are different situations.
If a prior authorization has been denied, see Prior Authorization Denied? What to Do Next in the Patient Survival Guide.
Ask about a formulary exception
If your plan does not ordinarily cover the medication you need, or covers it at a level that creates a serious affordability problem, ask whether an exception process is available.
Depending on your plan, your prescriber may be able to request coverage of a non-formulary medication or seek an exception based on medical necessity.
The insurer may require documentation explaining why covered alternatives would be ineffective, inappropriate, or harmful in your particular circumstances.
An exception is not guaranteed.
But “not preferred” and “never obtainable” are not necessarily the same thing.
Ask what process applies to your plan.
Manufacturer assistance may be available
Pharmaceutical manufacturers sometimes offer programs designed to help eligible patients obtain medications.
These generally fall into different categories.
Copay assistance programs may reduce out-of-pocket costs for some commercially insured patients using eligible medications.
Patient assistance programs may provide medications at reduced or no cost to certain patients who meet financial, insurance, or other eligibility requirements.
Eligibility can vary substantially by program and medication. Federal rules also limit the use of some forms of manufacturer assistance for people enrolled in federal healthcare programs such as Medicare.
Use the manufacturer’s official website or speak with your healthcare team to identify legitimate programs and current eligibility requirements.
Never assume that a website offering “prescription assistance” is affiliated with the manufacturer simply because it uses the medication’s name.
Look for independent assistance programs
Independent nonprofit organizations may offer financial assistance for certain medications, diseases, insurance premiums, or other treatment-related expenses.
These programs often have specific eligibility rules and limited funding. Some disease-specific funds open and close depending on available resources.
Your doctor’s office, specialty pharmacy, hospital financial counselor, social worker, navigator, or pharmacist may know which programs commonly serve patients with your diagnosis.
Because funding availability changes, verify information directly with the organization before relying on it.
Medicare has different rules and resources
If you have Medicare prescription drug coverage, your options may differ from those available to someone with commercial insurance.
Medicare beneficiaries may qualify for programs that reduce prescription drug costs based on income and resources. Medicare Part D coverage rules and out-of-pocket protections have also changed significantly in recent years.
Use current information from Medicare.gov or contact Medicare directly rather than relying on old articles about Part D costs.
State Health Insurance Assistance Programs, commonly known as SHIPs, also provide free counseling to Medicare beneficiaries and families.
Be cautious when buying medication online
A dramatically cheaper online price can be tempting when a prescription is unaffordable.
But not every website selling prescription drugs is a legitimate pharmacy.
The FDA warns that unsafe online pharmacies may sell counterfeit, contaminated, expired, or otherwise unsafe products. Some websites may also misuse personal or financial information.
Before purchasing prescription medication online, verify that the pharmacy is properly licensed and legitimate.
Price matters.
So does knowing what’s actually inside the bottle.
Don’t split pills or change doses without medical guidance
Trying to make an expensive prescription last longer by taking less medication can be dangerous.
Some medications can be safely split under appropriate circumstances. Others should not be split because of their formulation, dosage design, or other clinical considerations.
Skipping doses can also reduce effectiveness or create other risks depending on the medication.
If cost is forcing you to ration medication, tell your prescriber or pharmacist.
The affordability problem needs to be addressed directly rather than quietly changing the treatment plan yourself.
Keep track of what you learn
Prescription affordability problems can involve your insurer, pharmacy benefit manager, pharmacy, prescriber, drug manufacturer, and assistance organizations.
Keep a simple record of the information you receive.
Useful details include:
The price quoted by each pharmacy
Whether the price used insurance or cash
Your medication’s formulary tier
Prior authorization or step-therapy requirements
Alternative medications identified by your plan
Manufacturer assistance eligibility
Application or case numbers
Names and dates from important phone calls
This is particularly useful when different organizations give you conflicting answers about coverage or price.
Where to get reliable help
For questions about your prescription benefit, start with the member services or pharmacy number on your insurance card.
Your pharmacist can explain how a prescription was processed and may be able to identify lower-cost options or coverage problems.
Your prescribing clinician should be involved if changing medications, dosages, or treatment plans is being considered.
For information about drug approval, generics, biosimilars, and safe online pharmacies, use the U.S. Food and Drug Administration.
For Medicare prescription coverage and assistance programs, use Medicare.gov.
Your state insurance department may also be able to help with certain disputes involving prescription drug coverage, depending on the type of health plan you have.
The pharmacy price is information, not necessarily the final answer
When a pharmacist tells you a prescription will cost hundreds or thousands of dollars, it can feel like the decision has already been made for you.
It hasn’t.
Find out why the price is high.
Check the formulary. Ask about generics or biosimilars. Compare insurance and cash prices. Check other pharmacies. Ask your prescriber about appropriate alternatives. Investigate prior authorization, formulary exceptions, manufacturer programs, and independent assistance.
Not every option will apply to every medication or every patient.
But before deciding that you cannot afford the treatment your clinician prescribed, make sure you’ve found out what the medication actually has to cost for you.
