Saving on Prescription Drugs When You Have Drug Coverage

If you have insurance that covers prescription drugs then you don't have to worry about medication cost, right? Well, maybe or maybe not. Most probably, when you get a prescription from your doctor, you take it to your local pharmacy, and if you have managed care insurance, you pay a copay—your share of the cost. The online pharmacy then deals with the insurance company to get paid the other part of the medication cost. Most individuals have health coverage through managed care plans, and these plans provide prescription drug coverage with copays. The copays are usually fixed amounts, between $10 and $30, depending on what the plan designates in your contract. Usually the amount is fixed for a year, and that is how much you pay, regardless of the actual cost of the medication. So, if the medication costs $100 and your copay is $10, you pay $10. If your doctor prescribes another medication that costs $200, you still pay only $10. Your insurance pays the difference to the online pharmacy. Many managed care plans are now developing different copays for members based on the plan's cost for the medication. So, for example, a member might be charged a copay of $10 for the generic version of a drug but will have to pay a copay of $30 for the brand name.

There is a catch to the copay system, however. For you to pay only the copay, your doctor must prescribe a medication that appears on what is called a formulary, which is the list of medications that the insurance company has decided it will pay for. If your doctor decides that the medication that is the most appropriate for you is not on the formulary, he or she has to call the insurance company to justify its use. If the insurance company is not satisfied with the explanation, you will have to pay the full price of the medication.

If you have indemnity insurance that covers prescriptions, you pay for the medication and then submit a claim form to the insurance company to get reimbursed for all or part of the medication cost.

In all of the above cases, the out-of-pocket costs are usually small and most people who need medications for an acute condition can easily manage the cost. It starts to be a bit more complicated and expensive, however, when an individual has several chronic conditions and/or is on several medications. Even when you obtain your medications with copays alone, if you have several chronic conditions such as high blood pressure, high cholesterol, and diabetes, and are on several maintenance drugs, these copays can add up pretty fast.

The first step in managing the cost of prescriptions is to determine if the disease is an acute condition or a chronic condition. Acute conditions are illnesses that usually come on suddenly and whose treatments require relatively short periods of time, from a one-time therapy to a month or two of medications. Examples of acute conditions are pain after you see a dentist, an infection such as a strep throat or an ear infection, or a cold. Managing these conditions is not as expensive because once the treatment regiment is completed, the disease is usually cured.

Chronic conditions, on the other hand, usually develop gradually and when diagnosed, have to be treated for longer periods. Chronic conditions like diabetes and high blood pressure have to be treated for longer periods of time, even for life. It is important to realize that with these conditions, you have to continue treating the disease even when you do not feel any symptoms. Many of these diseases have to be "managed" because we do not yet have cures for them. When patients fail to follow treatment directions like taking their medicine every day, the disease can become more complicated and more difficult to manage. The result is an even greater expenditure on healthcare.

There are two strategies for managing the cost of prescriptions when you have coverage: mail order and samples.

Mail Order

Mail order is one of the least used and yet most effective means for saving money for those on chronic medications who have insurance coverage. To demonstrate: If you are a member of an HMO and you are given a prescription, you usually have it filled at a local pharmacy that accepts that insurance. If you are on chronic medication, such as a high blood pressure medication, you will be given a 30-day supply and be told to refill it as you approach the end of the 30-day supply period. You pay a copay every 30 days.

With mail order, you can request that your doctor give you a prescription for up to 90 days. You then send the prescription, along with your usual copay, to the pharmacy mail house that the insurance company has hired to manage its prescription drug program. The medication is sent to you by mail. The copay is about the same as the 30-day-supply copay you would incur at the local pharmacy. That means you are getting a 90-day supply for the same price as the 30-day supply If your copay were, say, $25 a prescription, you would have paid $75 to have filled it three times at the local pharmacy. By using the mail order, you might pay only $25 dollars for a 90-day supply, saving $50. Over time, or if you are on several medications, this can amount to substantial savings.

Mail order online pharmacies are able to offer such reduced costs because they deal in large quantities. They do not have to operate individual stores or pay a huge staff.

Pharmacy benefit managers (PBMs) operate most mail order companies. PBMs are companies hired by health insurance companies to help them manage the drug side of their business. Some of the largest PBMs are Diversified Pharmaceutical Services (DPSs), Express Scripts/ValueRx, and Merck-Medco.

The advantages to using mail order to obtain prescription drugs include:

Mail order is cheaper than going to your local pharmacy.

You maintain your privacy and get home delivery.

Mail order operations have become very sophisticated with computers that check and recheck prescriptions to ensure that there are no prescription errors.

If you have been with your insurance company for any length of time, the PBM will have a history of your medication. The mail order company can therefore detect if you are being given a medication that might cause a drug interaction with another medication you are on. This ability to catch a potential drug interaction might not be available at your local pharmacy if you have used different pharmacies to fill different prescriptions.

Mail order companies are usually designed to handle chronic medication schedules. This allows them to call you and remind you when you have to refill your prescription.

Most PBMs have web sites where you can view your medication history order medications, and review procedures. Issues regarding mail order operations include:

It takes time. Do not use mail order for acute situations, such as when you need an antibiotic for an infection. Mail order operations may take up to two weeks or longer to process and deliver your medicine.

When you order drugs by mail, be sure to make arrangements for proper delivery and handling when the drug arrives. This means that you have to be aware of extremes in temperature if the medication is to be left in a mailbox. If the temperature gets too hot or too cold and the medications are exposed to these extremes for long periods, they might get damaged.

Also be sure the medicines are not delivered and left in an area where children can access them and mistakenly ingest them.

Using a mail order pharmacy also takes away the personal touch you might have with your local pharmacy. You may be the type of person who finds this personal touch valuable and decide it is worth the extra money to have the reassurance your local pharmacist can bring. However, all mail order companies have customer service numbers that let you speak to a licensed pharmacist.

To order prescriptions by mail:

1. Call your insurance company and obtain the phone number of the company that manages its mail order services or inquire about the mail order services of discount pharmacy programs or Internet pharmacies

2. Call the mail order company to request the procedure for using the mail order system.

3. Request from your doctor the maximum number of days of prescription allowed by your plan.

4. Request the maximum number of refills allowed.

5. Submit your prescription, with your copay either by phone, fax, or mail.

6. You should receive your medicine within two weeks.

Samples

Samples are free medications provided by drug companies to physicians, to give to their patients. Samples are very useful, especially in acute disease states when the patient needs medication immediately and can't wait to get a prescription filled in a pharmacy. Pharmaceutical companies provide samples to physicians to start new patients on the drug to determine if the drug might work for the patient before committing them on the drug long-term. Samples also create brand awareness and build product loyalty. Samples can save you a lot of money. Doctors, by law, cannot charge for samples. In many acute conditions, such as a routine strep throat infection or acute pain, the physician might have enough samples to cover the whole course of treatment. If your doctor, therefore, gives you a prescription and you can't afford it, ask the doctor if he or she has free samples. Your doctor might have enough for the whole treatment or might have some to get you started and then you can fill the rest at the pharmacy, hence saving you money.

While samples are not ideal for chronic conditions, they nonetheless can be useful in chronic conditions as well. Your doctor might have "stock" bottles of medications. Usually samples are packaged to contain just a few pills to get you started on the drug. That's why samples are also referred to as starters. For chronic conditions, some drug companies provide physicians with containers that have up to a month's supply. Physicians have been known to sustain patients who cannot afford to buy medications for months on these stock bottles.

There are many benefits to using samples:

Samples are free. They have been used effectively by physicians to assist a lot of individuals who could not afford the price of the medication.

Samples result in high compliance. Many individuals do not fill the prescriptions their doctors give them. With samples, however, the patient is getting the drug directly and has a higher chance of treating the condition.

Samples help the doctor know if a particular medicine will work for a patient and if there are side effects that would make it wiser to switch to a different drug. Medicines do not all have the same effect on all patients, and other medications could be available for the same condition. By giving a patient samples for a short period of time, a doctor can determine if that patient should stay on that drug or try a different one.

Samples help physicians become more familiar with new drugs. When a new drug comes out, the drug company promotes it heavily and gives out lots of samples. While the patients benefit from this new therapy, the physician has the chance to evaluate for himself or herself how the drug really works. It also allows the doctor to know if there are special patient types that the drug works better in, any special conditions or circumstances to keep an eye out for, and any dosage adjustments that need to be made.

Certain issues must be kept in mind as far as samples are concerned:

Your doctor might fail to catch an important drug interaction. In a regular prescribing sequence, a patient receives a prescription from a doctor and uses a pharmacy to get the medication. With samples, the patient gets the medication directly from the doctor. In nearly every case, this works just fine. Pharmacists, however, play a role in catching medication errors and in checking for drug interactions. If a pharmacy is not involved, it makes even more sense to ensure that your doctor is aware of what medications you are taking, including herbal medicines. If you have any questions as to what you received, go back and ask your doctor or consult with your pharmacist. Another circumstance where a pharmacy can be of help is in the case where a medicine has been recalled because of safety or other concerns. If the pharmacy has a record that you are on the drug, at least another person besides your doctor can notify you.

Samples might not be properly managed. Federal law, state law, and private regulatory bodies require the proper handling, storing, and accounting of samples. There have been circumstances, however, where samples were not being properly handled or patients were given medications that were no longer useful. Although this is rare, ask your doctor if you have any doubts. Also check the expiration date on the package you are given to ensure that the medication is still good. A word of caution, though, about expiration dates: expiration dates do not always determine when a drug stops working. So your doctor might give you a drug that has recently gone past its expiration day. Bring the issue up with your doctor. If the expiration day was not that long ago, your doctor may say it is fine to use.

Be sure you are getting your sample from a person who is authorized to give you a prescription. While office staff members help the physician or prescribing personnel hand out medication, they can only do so with written orders from the prescriber. Be sure you are getting samples as a result of your doctor's orders.

Samples could cost you more money in the long run, because physicians give out samples of what they have and samples in physicians' offices tend to be of new products that are usually more expensive than older drugs. So, if you have a chronic condition and you were started on an expensive product, although it was free at the beginning, staying on it might become costly in the long run. If you are given samples of an expensive medication, be sure the samples are enough to cover you for the course of the treatment. If not, ask your doctor if a lower cost drug is available, which, although you might have to pay for it, ensures that over time you come out ahead financially.

About Drug Vouchers

Physicians normally get samples through sales representatives from pharmaceutical companies based on their specialty and prescribing habit. The practice location also determines what type of samples they receive. For example, office-based physicians get more pills and less of the types of products that are used in hospital settings such as drugs given intravenously.

A growing number of hospitals and other health institutions are now banning the use of samples, however. The reasons range from the difficulty of maintaining proper handling and management of the samples as required by regulatory bodies to the effect of drug samples on cost. An alternative to samples is the use of drug vouchers. With drug vouchers, patients receive a coupon for the drug, which they take to the pharmacy to receive the medication for free. The drug company reimburses the pharmacy for the cost of the drug.

Resources

For a complete listing of mail order companies, visit the web at www.managedcareregister.com. To learn more about samples, call the National Association of Boards of Pharmacy at (888) 481-9474, or visit their web site at www.nabp.net.

David Nganele. The Best Health Care for Less: Save Money on Chronic Medical Conditions and Prescription Drugs (2003)