A Pharmacist’s Guide to How to Lower Prescription Drug Costs
Payment Options and Practical Healthcare Steps
Written by Alexandria Yarborough, PharmD
As a community pharmacist, most of my day-to-day job entails verifying the accuracy of dispensed medications. This refers to making sure the medication I am dispensing matches the prescription order and exactly what the bottle says it is. However, there is an additional verification that I do that most people are completely unaware of: checking on your copay amount.
Although it’s not stated in the Oath of a Pharmacist, I view obtaining the best possible price for my patients as part of my duty. I can only speak for myself and my practice but this is true of every pharmacist I know. We are always looking out for you behind the counter and at the register.
Unfortunately, it takes time and we make mistakes when it comes to making sure you get the best price. Oftentimes, we need a new insurance card or an updated manufacturer coupon card (because it expired), as it always makes your brand name medication affordable. Other times, we might have taken a day off and the floater pharmacist isn’t aware that your insurance requires us to call and the prior authorization (PA) will immediately go through.
Getting the best price for you is our goal but doing so requires help from you. As the patient, it’s imperative that you provide us with the most up-to-date insurance card. I do recognize that you might not get sent one in the mail annually, so double check and see if your online account allows you to view it on your portal (they do!). Take a screenshot or save to your wallet, and you are good to go for an entire year!
Before I continue explaining how to get the best price for your medication, it’s necessary to understand how to pay for your prescriptions first. There are 3 main ways to pay for prescriptions: cash, discount card, or health insurance. Another option available are manufacturer coupons for brand name drugs–an additional cost savings benefit provided by the manufacturer. These can be used in addition to health insurance or separately.
Ways to Pay for Prescriptions
Cash
Please do not pay for anything with cash unless there are no other options.
When to Use: Sometimes your insurance plan does not allow for a medication to be covered and you need it. If you lose your medication, insurance will not often allow for an early refill or “lost” override. This is especially true if it’s a brand name. You can always pay cash.
Benefit: You are able to get your medication.
Limitations: Controlled substance law’s due dates still apply. If the law doesn’t allow for it to be filled on a certain day, paying cash doesn’t override that. The cash price doesn’t mean it’s less expensive. Medications can still be unaffordable.
Example: Some insurances limit the amount of the sleep medication Ambien® (zolpidem) a patient can get. For example, 15 tablets per 30 days. Due to this, a lot of patients will pay cash so they can get the entire 30- day supply at a time. Also, discount cards can’t always be applied to controlled substances. So, cash is the only option. It varies by pharmacy.
Discount Card
There are tons of options available but the most effective is GoodRx. You can go to their website and get a quote for how much your prescription will cost. Make sure the strength (usually mg) and quantity (qty) are correct. A quote for 30 tablets of a 5mg medication can be very different from a quote of 90 tablets of a10mg medication.
When to Use: You might not have health insurance or you might be prescribed a medication that is not covered by your insurance. Sometimes a medication might not be on their formulary or a prior authorization was denied.
Benefit: Your medication is much less expensive, but it’s not always at the low price insurance can offer. In addition, you might have a high deductible insurance plan and your copays are extremely high.
Limitations: Controlled substances such as Norco® (hydrocodone/APAP) or Adderall® (dextroamphetamine/amphetamine salts) are not often allowed to use a discount card. Discount card companies provide a discount to collect search data, medication info, and contact info to track usage and sell it to insurance companies, etc. They also might receive a profit when you use them. Medications paid for byon cash or a discount card do not contribute towards your deductible unless your insurance allows you to submit receipts for reimbursement. The price can change at any time unlike a set insurance copay. Finally, brand name drugs are often never discounted enough with a discount card to make them affordable.
Example: The cholesterol medication Crestor® (rosuvastatin) tablets are “covered” by your insurance, but the cost for a 90- day supply is $58. By using GoodRx, the cost is $24. Another example: You respond better to brand name Vyvanse® over the generic Lisdexamfetamine. The brand is not covered at any cost by your health insurance. The cash price is $460 and GoodRx allows the price to be $406. Both options are still unaffordable.
Right now, GLP-1 medications are extremely popular yet very expensive even when they are covered by insurance. Discount cards have now contracted with manufacturers such as Novo Nordisk to provide a discount through them for an affordable amount. The affordable amount, however, is subjective because $199 for a GLP-1 tablet might not be in everyone’s budget. It is important to note that the price is subject to change at any time and can increase with dose. For instance, Wegovy® tablets at 1mg on GoodRx/manufacturer coupon are $149 but once you are on the 9mg dose, the monthly cost is $299.
Insurance
This is usually the most cost effective option but not always the case
When to Use: Insurance is the gold standard for paying for medications but not everyone has prescription drug insurance. Other times, your plan might have a high deductible or coinsurance percentage calculation that makes your copay high. Sometimes you are required to reach a certain amount (a deductible or out- of- pocket maximum) before your copays are affordable.
Benefit: Usually the best cost option, but not always depending on your plan. Most manufacturer coupons for brand name drugs require a primary insurance to be used in combo with a manufacturer coupon.
Limitations: “Covered” does not mean $0. Covered means your insurance will allow it to be billed as a claim and you are responsible for a copay. This can be a set amount or a percentage.
Other times, a PA (prior authorization (PA) ) is required in order for insurance to process the claim. This requires your prescriber to contact your insurance company to let them know it's necessary for you to have this medication. PAs, when everything works well, take on average three3 business days. Most prescribers aren’t aware of what medication will require a PA. This requires a pharmacy to process a prescription, get a rejection, contact the patient and/or prescriber, wait, re-process daily, follow up with the prescriber, etc. A claim can still be denied if the PA is done. They often require certain diagnoses, trying other similar medications first, or other rules in order to be approved.
Insurance billing information can change annually or more often if it’s tied to an employer. Not all pharmacies are able to obtain the information for you. Important note: government issued insurance will not allow for billing of certain medications (usually over-the-counter drugs (OTCs) written as Rx), use of manufacturer coupons, or cash payments. Ex. Medicare Part D plans, Medicaid, or Tricare.
Example: Your thyroid medication is covered by your insurance. Each month you are able to get the brand name Synthroid® (levothyroxine) for $56. Thanks to a manufacturer coupon you obtained from their website, you are now able to get it for $25 each month. Without your primary insurance and manufacturer coupon, you would be required to take a generic option that you have not responded well to in the past.
WARNING: You should never pay for a discount card or a manufacturer coupon card. There are some companies that offer subscriptions for a deeper discount but those prices aren’t guaranteed, they’re an estimate. Other discount cards will promote themselves as an insurance plan and ask for payment to receive the information. They’ll use phrasing such as a “prescription card” or “savings benefits card,” but if you look closely, there will be an asterisk in small print that says “this is not insurance”.
Brand Name vs. Generic Medications
What Makes Them the Same
It might surprise you, but Brand-name and generic drugs are chemically the same medications. They are required by law to have the same active ingredient, dose, and safety or purity standards. Because of this, they are equally effective when taken, but differ mainly in cost, appearance, and inactive ingredients. When prescribing a medication, doctors must indicate with their signature (physical or electronic) if the generic substitution is allowed. There are rare instances where brand is preferred over generic. They include an insurance plan negotiating a contract with a manufacturer where the brand is preferred or if a patient has a known allergy to a certain inactive ingredient in a generic formulation.
What Makes Them Different
Generics are often cheaper because makers do not pay for original research or clinical tests. They will also differ in appearance, so colors, shapes, or sizes may change. Inactive ingredients such as binders or flavorings can be slightly different, though they rarely change how the medicine works.
An easier way to understand the difference is to think of baking a cake. Betty Crocker is a well-known cake mix brand. The mix is the same no matter if you buy a box at Publix in Florida or Target in Oregon. The mix would be the active ingredient. It’s a standard formula that will not vary. The difference comes from the eggs, water, and oil added to the mix.
Those are the inactive ingredients in this example. They are a necessary part of the cake but they aren’t required to be the same. You can use any brand of egg or oil. Sometimes people only use egg yolks or add extra ingredients such as milk. That might make the cake fluffier and that would be an approved additive. Now, if someone wanted to add tuna to the cake mix, that would quickly be rejected and the cake (or medication in this example) would never come to market.
Discount Card vs. Manufacturer Coupon
As a rule of thumb, discount cards work best on generic medications and manufacturer coupons work on brand name medications. Brand name discount cards are often used when there is no generic alternative. This is because companies are allowed a certain time after a medication is available to only sell the brand name drug. Once the license or patent expires, other companies can make the medication with the same active ingredient. Sometimes this is a few years. In other cases, it can be renewed multiple times and may last over a decade. Since a generic alternative is not available, manufacturers will offer a discount for patients with insurance. This way they are getting paid for the drug by the insurance but a cost savings is still achieved. These coupons usually expire at year’s end or have limitations.
For example, a coupon for Ozempic® allows insured patients to pay an average of $25 for a month's supply. However the max savings per month is $100. If your insurance cost is $46, the coupon will bring the cost down to $25. That’s great. But if your insurance cost is $399, the cost will be $299 with the insurance and coupon applied.
This can also get complicated because some coupons allow for true cash paying patients to use them and others do not. There are additional limitations on those if you have insurance or want to pay cash. You must first get a denial or rejection from your insurance to use the coupon. You are not legally allowed to claim you have no insurance if you do. That is against the coupon rules and can cost you in the long run.
Pharmacy Discount Programs
Some pharmacies offer their own discount savings. For example, Sam’s Club Plus Members are able to use their Sam’s Club membership as a discount card. This allows certain medications to be $0 or discounted. For example, a 30- day supply of generic Zoloft®, Sertraline 50mg is $0 on the Sam’s Club Plus membership whereas a 90- day supply is $8. Other pharmacies such as Walgreens or Publix use savings programs where you can look up your medication quantity and strength on their website. They’ll suggest multiple discount card options with varying prices.
How to get the best price at the pharmacy
When you are prescribed medication by the doctor, it can be difficult not knowing what the medication will cost. Sometimes, with common medications and uncomplicated health conditions you can assume the cost will be low. You are always welcome to ask the doctor what they think it will cost but their knowledge is limited. Their knowledge and that of other prescribers is generally limited to common generic medications that have been around for a long time. There is no way to know the cost of newer or specialty drugs
Insurance plans and formularies are often changing. For example, amlodipine is the generic drug name for branded Norvasc®. On almost every health plan, 30 tablets of Amlodipine 5mg is $0-4. The cash price without insurance is $10-20 at most. It’s an extremely important blood pressure medication that helps prevent heart attacks and stroke. Cheap doesn’t mean it isn’t necessary or life saving. If you were given a prescription for Amlodipine, you could take it straight to your pharmacy and ask what the price is, but generally, the pharmacies aren’t able to know what a medication costs when you bring in a prescription.
Once pharmacy staff input the prescription into their system and process it through your insurance, they will receive a copay amount. This requires time and you must give them your most-updated insurance and prescription billing information beforehand. Your prescription billing is often on a separate card. When your information is placed in your pharmacy’s system the first time, you do not need to provide it to the staff again until your health insurance were to change.
Looking up insurance information with generic medications is a pretty easy process at most pharmacies, but what if you are prescribed a medication that you’ve never heard of or the doctor isn’t aware of the price? The first step is to call the number on your prescription insurance card and ask what the medication co-pay will be at your preferred pharmacy. They will also tell you if it needs a PA or if it’s not on their formulary. Sometimes, it might be considered a high-tier drug. This means they will allow the medication to be paid for but a high cost. A lot of times the language used is extremely confusing. Please be aware that when an insurance company says something is “covered”, it means they will process the claim, but it does not mean it will be $0.
A Crazy Yet Not Uncommon Example
Let’s imagine you’re having sleep issues and are prescribed Lunesta®. I’ll illustrate the steps and delays that could happen. This is an extreme example, but one or two of these issues may occur. Let’s pretend the generic is unavailable. Here we go!
You take your prescription to the pharmacy, but insurance requires step therapy. You call your insurance and learn they want you to try Ambien® (zolpidem) first. The pharmacy can’t change the prescription, so you leave your doctor a message.
Two days later, a prescription arrives for 30 tablets with five refills. It’s Friday, and the pharmacy is out of that strength. You wait for Monday’s order.
Once it arrives, insurance rejects the claim because of a quantity limit. They’ll cover the generic, but only 15 tablets at a time. Your options: Get 15 through insurance or try a discount card for 30.
You choose insurance, and the medication works well. You return every two weeks. You ask about paying cash for another 15 tablets, but this pharmacy’s system allows only one fill per prescription daily.
Then comes another surprise: Depending on how the fills are processed and applicable requirements, those smaller quantities may mean needing a new prescription sooner than expected. You’re out of medication and must contact your doctor again.
Here’s an alternative: You want 30 tablets with a discount card, but this pharmacy doesn’t accept discount cards for controlled substances. Another pharmacy does. You ask about transferring the prescription, but transfer requirements create another hurdle. You end up paying cash.
Fast forward three months. You’re having side effects, so your doctor tells insurance the step therapy failed and requests Lunesta® again. That requirement is satisfied, but prior authorization is still needed.
Four days later, it’s approved. The generic would cost $12 monthly, but in this example, a recall has made it unavailable. Fortunately, your pharmacist knows about a brand-name manufacturer coupon and directs you to the website. You obtain the coupon and bring it back.
There’s a line, and the pharmacist is giving immunizations. After 30 minutes, the technician processes your coupon. It works! The brand will cost $50 monthly, but your strength must be ordered.
You return early the next morning because you’re leaving at 11 a.m. for a weekend trip. Unfortunately, the order arrives at 3 p.m., and your medication won’t be ready until 6.
After 10 years of practice, I’ve never had one prescription with this many issues, but one or two are common, especially with new medications. Backorders, controlled substance limitations, and insurance requirements can cause delays. Cash prices can reach hundreds or thousands of dollars.
I love saving patients money! I try my best to find every patient the most affordable price. Unfortunately, that takes time, and price discrepancies happen. If something seems wrong, please be kind and talk to a pharmacy staff member. We want to help! My pharmacy’s membership discounts and workflow sometimes give me flexibility to explore savings, but every pharmacy is different. Many pharmacies are extremely busy, so providing the information we need helps us process your prescription correctly.
How to Be a Responsible and Successful Patient
This requires you to be patient and to be your own advocate. If you get a prescription and want to know the cost, call your insurance company or look up the average price on GoodRx. If it’s a brand name, search the name of the medication and coupon. If you’re unsure, search the name + “brand?’ or “generic”. The pharmacy staff is here to help you get your medication, but we are unaware of what insurance plans charge for medications, their requirements, what tier a certain drug is in, or how close you are to your deductible. We only know what the insurance plan tells us when we process a prescription.
I personally work at a pharmacy that offers discounts on certain medications with their membership plan. and I can tell when certain generic drugs can be less expensive. I also am a medium- volume pharmacy and have more flexibility than most pharmacies to look and see if you’re able to get a manufacturer coupon online. I love saving patients money when I can, but it's the patient’s job to provide their insurance information, discount card, and/or manufacturer coupon. Pharmacy staff can point you in the best direction for savings, at times, but it is the patient’s responsibility to do their research.
Want to hear more from Brandy? Check out the YMyHealth Podcast on our YouTube channel or on your favorite streaming platform!
For more guidance to understanding insurance and prescription drug terms, visit Dr. Alexandria Yarborough’s Pharmacy Glossary here.