Understanding medication coverage and navigating your pharmacy benefits plan can be extremely perplexing. As prices for medication can vary widely and formularies constantly change, you want to make sure you are paying the lowest possible amount for any medication you are prescribed. First, it is important to have an understanding of how pharmacy benefits work.

What You Can Do to Reduce Prescription Costs

Even with insurance, medication is not necessarily cheap. In fact, your prescription benefits are not provided by your insurance company directly, but rather by a pharmacy benefit manager (PBM). The PBM subcontracts with the insurance company and acts as a liaison with the pharmaceutical manufacturers. This can mean an increase in prescription costs for you.

You should be aware that there are different tiers and costs for co-pays based on your benefits plan, depending upon whether the medication is a specialty drug or generic. Often, you may not even know how much your prescription will cost until you arrive at the pharmacy to pick it up.

If your health issue is urgent, you may have to get your prescription filled immediately regardless of the cost. However, if you require medication for a chronic condition such as asthma, diabetes, or mental health-related issues, it may be a good idea to investigate alternatives that could save you a large sum of money.

Research Coupons

If your health issue is chronic and requires ongoing medication, you will want to make sure that you are paying the lowest cost possible. There are many websites such as goodrx.com that provide coupons to purchase drugs off your health insurance plan. These sites may allow you to save as much as 80% off your prescribed medications.

Order a Three-Month Supply

If you require ongoing medication, it may help you reduce costs by purchasing in bulk. Many mail-order services allow you to purchase a three-month supply for a discounted price. For chronic conditions, larger pharmacies such as CVS may automatically change your prescription to a three-month level.

Investigate Alternative Prescription Services

There are many alternative prescription services that you may consider to make sure you’re getting the best available price for your medication. In a state such as New York that no longer uses paper prescriptions, you will first need to get the dosage and drug information from your doctor to shop around for a lower price than is being offered on your pharmacy benefits plan. Consider researching the prices available by mail order, at local pharmacies, and online prescription filling services.

Find Out if You Qualify for a Patient-Assistance Program

Many drug manufacturers offer financial assistance programs to patients with chronic conditions. Some conditions such as Crohn’s and colitis require treatment with expensive drugs that could cost up to thousands of dollars each month. In these cases, co-pay programs offered by manufacturers may offer substantial savings to you.

Some manufacturers may only offer financial assistance if you have insurance. Whether you are self-pay or have insurance, it is worthwhile to investigate whether you could qualify for a patient-assistant program that could end up saving you a fortune.

Understanding Formularies and Formulary Exceptions

A formulary is a list of generic and specialty drugs that are covered by your particular pharmacy benefits plan. However, formularies change every year — you may be surprised to see that a medication you were prescribed was covered by your formulary one year, and the next it isn’t. This means that you can suddenly be hit with significantly higher costs if you continue the same drug.

If a medication you have been taking and tolerating well is no longer on your formulary, there are ways to have it covered by your plan.  In some instances, your plan will require that you be prescribed other medications — often older and less expensive treatments — prior to being approved for the current medication.  If your doctor can demonstrate that the approved treatments have not been successful in treating your condition, it is possible that the plan will approve the prescribed medication.  In other instances, you can avoid this stepped treatment by having your doctor request a formulary exception, in which s/he demonstrate a clinical need for this medication. It is often worthwhile to go through this process with your doctor as it would allow you to continue the same medication, rather than switch to a different drug.

How an Experienced Medical Bill Advocate Can Help

If you are facing significant medication costs, or have received an excessive medical bill, an experienced medical bill advocate can help save you thousands of dollars. Systemedic is a nationally-recognized medical billing advocacy company with decades of experience in helping victims of fraudulent and unethical medical billing practices and assisting patients to access the most cost-effective prescription options. If you are experiencing a medical bill dispute or significant pharmaceutical costs, contact Systemedic today at (845) 639-0007.

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