How Can My Doctor’s Office and Pharmacy get involved when a prescribed medication is too costly?

You may find yourself trying a different treatment regimen while you and your doctor work to discover what is best for your unique health situation. It is important to keep track of how each medication works and be able to provide feedback to your prescribing doctor about the effectiveness of the new treatment as well as any side effects you are experiencing. It is equally important to understand your health insurance plan and any out-of-pocket cost-sharing you are responsible to pay such as deductibles, co-pays and co-insurance.

Since medications must be paid in full before you can pick them up, it may cause significant financial strain, hinder your ability to fill the medication, or affect you being able to take the medication the way it is prescribed. Before you walk away from the counter or purchase a medication you cannot afford, talk to the pharmacy and check some basics. Be sure the pharmacy has your current insurance information on record and correct any incorrect information.

You also need to verify if the pharmacy is in your provider network. Your insurance plan has arranged for a specific list of network pharmacies to serve you. Even if you have been going to the same pharmacy for a long time, these contracted relationships can change at any point. If your pharmacy becomes out-of-network and you have limited out-of-network benefits, your insurer may not pay anything towards the cost of your medication.

It is becoming more common that insurance companies mandate that medications must be filled through a mail-order pharmacy and are not offered at a retail pharmacy location. Some plans have language in place that limits you to get your first fill of a medication at a retail pharmacy, and then requires that you use a mail-order pharmacy for all maintenance medication refills.

If the cost is still too high for you, speak to your medical provider or pharmacist about other options for cost savings, such as store brand discount cards, co-pay assistance programs or manufacturer coupons. A great resource to explore is www.needymeds.com. You can search by drug name, manufacturer, disease and state resources. There are also programs available through the pharmaceutical manufacturers for those who lack insurance or coverage for prescriptions that allow qualified individuals to gain access to medications at no cost with the support of their prescribing doctor.

Lastly, if none of these suggestions help, see if there are alternative medications or any generic option for a specific drug that you can try.

Looking long term, during your annual open enrollment period, you want to review your current health insurance plan drug coverage and compare it to other available plan options. Assess your current treatment and possible future treatments to help determine if you should consider changing plans to have better coverage available that will provide additional cost savings. Sometimes this means you must pay higher premiums to ultimately lower your out-of-pocket cost.

If you have tried all these methods and still find yourself unable to afford your prescribed treatment, Patient Advocate Foundation can help. Reach out at www.patientadvocate.org/migrainematters or call 1-800-532-5274 for support.

by Erin Bradshaw
Chief of Mission Delivery
Patient Advocate Foundation