By NerdWallet Health health finance expert Christina LaMontagne
I take several prescription medications to manage my multiple sclerosis. Most of them are covered by my health insurance, but one medication recently prescribed to help with my fatigue is not, and costs more than $100 each month. I thought all prescriptions had to be covered under my insurance. If I have to pay out-of-pocket, what can I do to make this medicine more affordable?
Prescription costs can add up quickly, even when you are only paying a copay. But when your health insurance doesn’t cover even one medication, the added financial burden can be considerable.
Under the Affordable Care Act, health insurance companies must provide prescription drug coverage—even Medicare prescription coverage is changing. However, that does not mean that they have to cover all prescription drugs. For your situation, it’s important you talk to your health insurance company to find out why they aren’t covering the costs of this single prescription.
Tip #1: Find a less expensive alternative
If the company doesn’t cover the cost of that drug for anyone, talk to your doctor about covered alternatives. Perhaps there is a similar medication that is covered by your policy. On the other hand, you may discover your insurance company denied your coverage due to an error, or the belief that it’s not medically necessary. In that case, your prescribing physician may be able to help by correcting the mistake or appealing to the health insurance company and explaining the medical necessity of the drug. You may be able to take a series of steps to prove to your insurance company that the drug is medically necessary, but you’ll have to get in touch with your insurance company to figure out how to do this.
Ask your doctor for any samples the office may have. Though this is only a short-term solution, every bit helps. The medicine may also be ordered at a higher dosage amount, coming in larger pills that can be split in half. While this isn’t possible for all medications, it can cost less than buying more pills at a lower dosage.
Talk to your pharmacist about whether the drug has a generic version. Generic drugs cost an average of 80% to 85% less than brand-name versions, according to the Food and Drug Administration, and are required to be of the same quality and performance. If there isn’t a generic version yet, this would be another good time to discuss alternate medications; your pharmacist may have ideas your doctor overlooked. Typically, there are several drugs from different manufacturers created to treat the same condition, giving you the ability to shop for the most appropriate solution.
If those options don’t work and you are stuck with the added expense, you still have options.
Tip #2: Comparison shop to find the most affordable pharmacy
Additional options for saving on your prescription costs involve smart comparison shopping, as you would undertake for any high-dollar item. Compare the price of your prescription at a few pharmacies in your community, and check for additional savings on coupon websites like GoodRx.com. Also look online for mail order prescription services, choosing only those accredited by the National Association of Boards of Pharmacy, marked with a “Verified Internet Pharmacy Practice Sites” (VIPPS) seal, to ensure their safety and legitimacy.
Tip #3: Look for financial assistance programs
After speaking with your doctor and pharmacist, turn to the drug manufacturer. Pharmaceutical companies often have patient assistance programs for people who need their products but struggle to afford them. The Partnership for Prescription Assistance can direct patients to these programs and others offered through nonprofit organizations.
Prescriptions can be a significant expense when you rely on several medications to maintain your health or treat an illness. Determining how best to save money while maintaining the prescribed treatment protocol could require some homework on your part. But with several possible money-saving options available, that homework could pay off.
NerdWallet Health helps patients reduce their medical bills—get started at health.nerdwallet.com. Have a question for Christina? Submit it to AskChristina@nerdwallet.com.