HYANNIS – In general, seniors take more prescription drugs than other people. Since they are usually also retired and living on a fixed income, this can be an expensive proposition. It doesn’t help that insurers, including Medicare Part D, have what amount to “gag orders” that contractually prevent pharmacists in some states from disclosing the fact that the cost of a prescription may actually be less than the patient’s co-pay – unless a patient asks.
It’s a bigger problem than people realize. In March 2018, researchers reported in the Journal of the American Medical Society (JAMA) the extent of overpayment. They analyzed 9.5 million claims and discovered that in 2.2 million claims, the co-pay was higher than the cash price. For 12 of the 20 most commonly prescribed drugs, patients overpaid by more than 33 percent.
The gag orders are part of many of the contracts between pharmacies and the pharmaceutical benefit managers (PBMs) that are the middle agents between the insurance companies and pharmacies. So far, 21 states have banned the PBM gag orders, but Massachusetts is not yet one of them.
That doesn’t mean that you can’t save money, according to Angela Medeiros, director of the retail pharmacy at Cape Cod Hospital. Medeiros offers the following tips to consumers trying to save money:
Ask About Pricing
“Your pharmacist wants to help you, so ask questions about how you could reduce your pharmacy spending,” Medeiros said. “If you are willing to ask questions and be patient, you might be able to save money.”
Even though high-paced pharmacies are busy places, if you make a list of all the medications you take and the name of your insurance company, most pharmacists will be able to offer suggestions for ways to save money, she said. Just give them a day to do it so they can fit it in when they have time.
“The days of just getting your medical treatment and not asking questions are in the past,” said Medeiros. “You really have to be your own advocate and ask how much things are going to cost before you actually go forward with them.”
You should always ask the pharmacist what the cash price is and compare it to your co-pay. A lot of pharmacies do AAA discounts, which might help tip the cash price to a lower amount than the co-pay. Large pharmacies also offer discounts if you buy your medications in bulk, such as 30-day supplies.
If you do pay a lower cash price, be sure to submit the proper documentation to your insurance company for the purchase. Many people don’t know that insurers must count any cash purchases toward their out-of-pocket expenses.
Those who spend a lot of money on medications could trigger the donut hole, which is a gap in prescription coverage that is part of the Part D of Medicare. This year, the gap begins after the insurance plan and beneficiary have spent $3,750 and ends once the beneficiary has spent a total of $5,000.
If you do fall into the donut hole, make sure to research federally funded discounts which can be up to 65 percent on brand-name drugs and 56 percent on generics, according to Interactive Medicare.org, an online curriculum designed to help navigate Medicare questions.
Talk To S.H.I.N.E.
Medeiros is a S.H.I.N.E. ((Serving the Health Information Needs of Elders) counselor and said there are a lot of ways for people to save money that most are not aware of.
“One of the options that a lot of people in Massachusetts don’t know about is Prescription Advantage,” she said. “It’s a secondary prescription insurance that has different levels of coverage where it may help pick up your co-pays for you, depending on your income.”
S.H.I.N.E. volunteers can also find out if a senior qualifies for Mass Health, as well as Medicare and direct you to other resources in the community such as the Frail Elder Waiver that allows frail people with higher incomes to qualify for assistance.
Ask For Alternatives
“Anytime you are surprised by the cost of a drug, it’s very reasonable to ask your doctor or pharmacist if there is another, less expensive alternative,” Medeiros said. This is one of the easiest ways to save money at the pharmacy.
Contact The Manufacturer
A lot of companies that manufacture high-priced drugs like brand-name inhalers for asthma or COPD offer co-pay assistance, Medeiros said. You can look on the company’s website for a coupon or call them to see what help they can offer. You can also ask a specialty pharmacy for help negotiating the price of extremely expensive medicine.
“We have some people internally that work at our Cape Cod Healthcare Specialty Pharmacy that do benefits investigation for high cost medication,” she said. “We just recently were able to get a $30,000 drug for a patient for free through the manufacturer, because the patient was in between jobs. Our pharmacists worked really, really hard to do that, but it happened.”
Contact Your Insurance Company
All insurance companies are different, Medeiros said. Sometimes pricing or the list of possible medications you can take has more to do with the contracts the PBMs have with specific manufacturers than anything else. Most prescription insurance plans have pricing tiers. The tiers are designed to offer financial rewards for using generic and preferred drugs by requiring patients to pay progressively higher co-pays for the preferred name-brand name and the non-preferred brand-name drugs.
If your co-pay for a certain medication is high, call the number on the back of your insurance card and ask if there is a substitute medication they would prefer that you take. Once you have the answer, talk with your doctor about whether it is a good option for you.
Ask About Lifestyle Changes
“Diet and exercise are really the most important forms of medicine,” Medeiros said. “There are little to no adverse reactions with both of those options and the benefits to one’s health are countless. That should always be step one. Can this be treated with lifestyle changes like diet and exercise?”
Other lifestyle changes she suggests:
Smoking cessation
Lower alcohol consumption
Lower caffeine consumption
Limiting sodium consumption
Control your blood sugars and reduce the amount of sugar you eat
Lower cholesterol consumption
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