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A national 501 (c)(3) non-profit charity that provides direct services to patients with chronic, life threatening and debilitating diseases to help access care and treatment recommended by their doctor.
Talk to the Pharmacist – Is There a Lower Cost Alternative Available? If so, the pharmacist may be able to call the ordering provider and see if your doctor is willing to prescribe a clinically equivalent drug. However, asking for generic drugs may not always be the less expensive option depending on your health plan’s structure. Is there is a manufacturer’s coupon that you can use? If so, this may bring the cost of the medication down to the generic range.
You Can Call the Insurance Company Directly – This will put you in touch with the Pharmacy Benefit Manager (PBM) for your plan, and they should be able to provide you with a list of comparable alternatives that are on your drug formulary. You would still need to speak with the ordering provider to see if changing the medication is an option.
Do You Take the Medication More Than Once a Day? If so, ask your doctor if you could take a stronger dose less frequently, or maybe split a stronger dose pill in half and take half of a pill twice a day without causing negative side effects. This may save you money in the long run.
Use the Money You’ve Put Aside in Your Health Savings Account (HSA) or Flexible Spending Arrangement (FSA) Accounts. Prescription drugs, as well as over-the-counter medications and supplies, are eligible for reimbursement through tax-free money accounts you’ve put aside to help pay for medical expenses.
Other Ways to Find Lower Cost Medications You may be able to get a better price on the prescription without your insurance. Depending on the medication, common generic options are often available through a discounted program from the retail pharmacy chain. However, if you do not use your insurance to purchase your medication, the cost will not be applied to your annual deductible.
There also may be prescription savings websites that could save you more than your insurance discount. Select the brand, dosage, and quantity of medication you need, and then scroll through local pharmacy listings for the best price. Don’t forget to shop around for the best price at local pharmacies, because different stores have different prices.
If you take brand-name medications, check for manufacturer discounts or co-pay cards on the manufacturer website prior to going to the pharmacy. People covered by government-sponsored insurance such as Medicare, Medicaid, or TRICARE may not be able to use the co-pay cards.
Most insurance plans offer a discount if you are willing to obtain your maintenance prescriptions through their mail-order pharmacy program. This allows you to get a 90-day supply of medication at one time, often at a reduced cost than retail pharmacies, and the medications are delivered right to your home. If you need medications immediately, choosing mail order would not be the best option.
Common Medication Denial Reasons
•Incomplete or inaccurate insurance information submitted
•Lack of pre-certification or prior authorization on file
•Step therapy requirement before approving a more expensive medication
•Diagnosis and procedure coding errors or omissions
•Off-label use for the medical diagnosis
•Quantity limits are exceeded
•Off formulary (not truly a denial but results in no coverage)
This information is part of the “It Matters Empowerment Pathways” content series developed as part of the Matters of the Heart project.