Do you or your loved one have an ongoing condition where you need to take medicines every day? You can manage the costs of your prescription drugs. The costs of medicines add up quickly. Get tips for what you can do to keep your costs as low as possible.
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Joyce Griggs: Hello everyone. Joyce Griggs here from United States of Healthcare, and I'm here with our expert, Dr. Alan Feren, and we're talking today about insurance and we're talking about costs and, specifically, prescription drugs, your medicines, and what goes into choosing your health insurance and what things can we do to control these costs?
And there are some pretty surprising things that we can do and what we need to consider. So welcome Dr. Feren. Thank you so much for being with us today.
Alan Feren, M.D.: Thank you, Joyce. Happy to be here with you.
Joyce Griggs: So in this conversation, we're gonna focus really on chronic ongoing conditions, right? Things like hypertension, high cholesterol, erectile dysfunction, heart disease, chronic pain, all these different things, where we're taking medicines on a regular basis and there are some other aspects of prescription drug cost management, but we'll get that at another day. This is really for those of us who are taking medications on a monthly basis and this can really get into, you know, hundreds of dollars, thousands of dollars for some of us.
Alan Feren, M.D.: Thousands for sure.
Joyce Griggs: Right? But even if it's $20, you know, these costs add up over time. So, okay, so what are the things we need to know so we can make the right choices and also prepare ourselves for these monthly costs when it comes to prescription medicines?
Alan Feren, M.D.: I think it's important to understand the difference between the various types of drugs.
Generics are obviously are first and foremost in everyone's mind because over the years we've seen the transition from brand name drugs. So those are drugs like Lipitor, let's say cuz it's a very common drug. And the generic name for that is atorvastatin. And when you are given a prescription for Lipitor, on the prescription form there is two boxes. One is "do not substitute." The other is " please substitute".
Most health plans, and we're gonna talk about formularies very shortly, will require physicians when at all possible to use generic drugs for the vast majority of these chronic illnesses, for hypertension, abnormal lipids, hyperlipidemia, elevated cholesterol, for diabetes et cetera.
So generic drugs, to be clear, have the same safe and effective active ingredients. And the reason why a generic drug is less expensive than a brand name drug is that it does not have to go through all the steps that a brand has already gone through to prove the safety and efficacy of that particular drug. Where a generic drug may differ from a brand name drug is the inactive ingredients so that the same safety profile and the same effectiveness of a generic drug is okay and it's been shown to be safe for you to take. So atorvastatin generic is basically the same drug as Lipitor. But there are other drugs that have different inactive ingredients that may be responsible for what people experience as a side effect of a generic versus the side effect of a brand that perhaps they were taking before and didn't have that same effect.
The other thing that I have seen in practice is someone will tell me, I tried this generic drug. It doesn't work. It's not the same as the brand drug. And the reason for that is definitely that the generic drug may be metabolized by the body differently than the brand because of the inactive ingredient. It's not that the drug is not safe, it's not that it's not been approved by the FDA, all generics have to be approved by the FDA. It's that the inactive ingredients and the metabolism of your particular body may be different than the way the brand drug is metabolized.
The other thing to remember is that oftentimes many of the generics come off the same manufacturer line as the brand. So it's not that it's that much different, but it is very cost effective compared to the brands.
Joyce Griggs: Okay. So something to take into consideration is that, generally speaking, the generics work as well as the brand names, but it doesn't mean that you as an individual might have a different response to it based on some of those things that you said. So it might not work for you, or you might have a different side effect, but for the vast majority of us, it's completely fine and a great way to get the medicines we need at a cost that's very affordable.
Alan Feren, M.D.: Correct.
Joyce Griggs: Okay, super. Awesome. So we were talking a little bit now about our insurance plans and how they covered these drugs. Can we talk about that a little bit about, you know, how they get paid, how we pay, and how we can benefit or not benefit?
Alan Feren, M.D.: Sure. Well, I think that the important thing to understand here is the formulary. Formulary in simple terms is it's a drug list. It's a list of the drugs that your health insurer has agreed to cover for your, rather than using the term "chronic," I like to use the term "maintenance medications." They are taken on a regular basis, and that's certainly the definition of what's chronic, but I like to use the term "maintenance." It's just a, I think it's a softer term, so to speak.
So a formulary is a drug list. The drug list is determined by your health insurer. They sit down with what's called a PBM, which is a Pharmacy Benefits Manager to determine what drugs are gonna be in that health plan's formulary. Those decisions are really primarily based on the safety and effectiveness of a particular drug over a brand drug that's bioequivalent, the effectiveness of that drug, and particularly what the cost is.
So, PBMs, Pharmacy Benefit Managers, negotiate a rate with your health insurer, and then these rates then are based on usually four tiers of medicine. The first tier is typically generics, and that's the least expensive form of drug distribution.
The second tier are preferred brands. They're preferred because of the safety profile, effectiveness, convenience, but also price. And there will also be some generics that are of a higher price in that second tier.
The third tier are the non-preferred brands, and of course these all are gonna vary depending upon the PBM and how it negotiates with the individual health insurer.
The fourth tier are typically drugs that are injectables, like Humira for rheumatoid arthritis, or the so-called biologics. Those are the most expensive. Those do not have typically a copay, but they have a co-insurance. In other words, you're gonna pay a percentage of the cost of that drug, and it's typically around 20%. Whereas copays can be anywhere between $5 and $10, depending upon your plan and depending upon which tier you're in. So, for example, a tier three, the copay is gonna be the highest. Tier two, it's gonna be a medium. And tier one, it's gonna be the lowest, and that's typically the $5 or $10.
This is really important information.
Joyce Griggs: And can we get access to this list, Dr. Feren, from our insurers or how do we know?
Alan Feren, M.D.: Yeah. Yes, your health insurer will provide you with a formulary. So going back to your previous discussion with Jordan Shields about selecting a health plan.
Joyce Griggs: Yeah.
Alan Feren, M.D.: One of the things you're gonna wanna do is get the health plan's formulary so you can take your maintenance medications, plug them into their formulary. Now, it's important to understand that formularies change throughout the year. So you can have a drug that was initially a tier two, pushed into a tier three, or it could be taken off and be a non-covered drug.
You're gonna be getting updates on a regular basis for that health plan's formulary. So it's important for you to be aware that these changes will occur.
Joyce Griggs: Okay. And then to talk with my doctor or my nurse practitioner about there's been changes and maybe that medication isn't affordable for me anymore. What can we do?
Alan Feren, M.D.: Well, unfortunately, your doctor, nurse practitioner is not gonna know the various formularies. But if, if you are taken off a particular drug or if it becomes unaffordable for you, that's the discussion that you have.
With the electronic medical records, at least physicians now have a little better sense for what's typically covered by your health plan. Whereas prior to electronic medical records, that was not the case.
Joyce Griggs: Right, right. So I mean, it's really more my responsibility or our responsibility to tell our healthcare professionals what we know to be covered or not. I mean, it would be great if they could tell us, but they can't always do that. But if we are on a medicine and suddenly it becomes very expensive cuz it's been moved a tier, and we find that out at the pharmacy on, you know, one day, but it would be up to us then to take that to our doctor, a nurse practitioner, and say, "Hey, there's been a change here. Is there anything else that I can take?" Because sometimes there are other options. I mean, you're not between a rock and a hard place always.
Alan Feren, M.D.: And when you get to that pharmacy and you find out that that drug that you had been paying a $10 copay is now $200, don't pay the $200.
Joyce Griggs: Oh.
Alan Feren, M.D.: Tell them to cancel that prescription or call and cancel that prescription because there are ways to reduce those costs, but with a substitute medication that typically will be available for you.
Joyce Griggs: This is great. This is really important information because so many of us would just pay it. I love that. So, okay, so now we know that we have the formulary, the drug list that they put together at the insurance company. We know the different levels that our medicines are on and the costs associated with that.
Are there other things that come into play that could impact the cost of our drugs or our access, I guess, to these medicines?
Alan Feren, M.D.: Sure. Absolutely. There, there are ways that you can save some money on drugs that can be considered. One is, when you're first started on a new drug, let's say you have a new diagnosis of high blood pressure, hypertension, and the doctor prescribes a medication that is generic. It's relatively inexpensive. You can either go and have that filled at your local pharmacy, but another way to find out whether or not this is the right drug for you and not have any out-of-pocket expense whatsoever is to ask the doctor, are there samples for me? Doctors are detailed all the time by pharmacy representatives. And when I was in practice, I always asked for samples, but I also asked for the literature behind the samples. But I used those samples for my patients to allow them to try a medication to find out whether or not it was safe and effective for them.
So that's the first thing I would do, is ask your doctor for samples.
Joyce Griggs: Samples is a great idea.
Alan Feren, M.D.: Yeah. The second is if they're starting you on a dose, let's say that's 10 milligrams and you have a tablet, you can get a pill cutter and cut that tablet. That is relatively safe. Pharmacists will tell you it's not exactly safe. I would say that if you cut it in half, the likelihood is that the distribution of medication within that tablet is probably pretty uniform, and I would not worry about it. Capsules. No, I would not. If you try to pull apart a capsule and empty out half of it, that's not gonna work. I do not recommend that. You did not hear that from me. So, pill cutting I think is a safe and effective way to reduce costs so that the doctor can prescribe typically a dose that you can safely cut in half, that will reduce the cost of your prescription.
The third is that for very expensive drugs, there are programs that the manufacturers typically will offer or coupons that are available. There are places like GoodRx that are universal in the United States.
Out of country purchase, I know is controversial. Canadian pharmacies, not all of them are safe. Perhaps maybe not safe. I would be wary of some of the foreign pharmacies, but there are a number that are tried and true and use the same drugs that we use in the US.
There is a Israeli pharmacy, as well. There are some newer pharmacies that are now available in the United States that have a specific cost for the drug and then a charge above their own cost. So what they are doing is basically bypassing the PBMs and negotiating directly with the manufacturer to get a more favorable price. So those are all things that I would consider to be potential cost savings for people on maintenance medications.
Oh, and I forgot to mention, don't be afraid to use mail order pharmacies. They really save a lot of money and have a tremendous convenience factor. They even have auto refill for you so that you really don't have to be concerned about running out of medications because they will, before you run out, notify you that it's time to refill or say, "Your refill is in progress."
Some people like to just keep track of that. My wife absolutely doesn't like auto refill. I like auto refill. I have a busy life and I can't remember until my pill boxes are empty that there's gonna be a problem.
Joyce Griggs: I think that's really exciting, right, the new things that are happening in terms of these new pharmacies that are available to us right here in the United States that are really helping us, everyday people, just to be able to afford medicines and not have to make difficult choices.
Alan Feren, M.D.: Yeah. I would also add in the big box stores. Big box stores typically have pharmacies that are less expensive. These would be the Targets, the Costcos, and so forth. So don't be afraid of those. Those are excellent places to get safe drugs from.
Joyce Griggs: That's awesome. Now, are there other things that we should talk about as it relates to like access to our medicines? For example, one of the things I think we touched on, you and I, in one of our conversations was quantity limits. And I was trying to wrap my head around what the heck is a quantity limit and, you know, how, how can I manage this? Can you talk about that a little bit?
Alan Feren, M.D.: Sure. First of all, it's a giant headache for for many people. So PBMs and insurance companies are very rigid about quantity limits. In other words, if your doctor prescribes one pill a day to be taken and you typically will get a a refill either on a monthly basis or a three monthly basis. So, if you're given 90 pills for a three-month supply of your maintenance medication, that's all you're gonna get. If you ask for a refill before, you're gonna get a notification from your insurance company or from the pharmacy benefit manager that it's too early to refill. You can get insurance overrides, for example, if you're gonna go on an extended trip, if you're gonna go out of the country and you're gonna run out of medications. Then it's important to contact your primary care provider or your prescribing physician to let them know that you're gonna be leaving town and that you will need to have medications for that.
In the event of an emergency, you typically can get medications from a pharmacy, they'll give you a quantity to get you through, but it'll have to be approved through your physician. So that's one thing to be aware of. For those of us who are not using mail order, who are not doing auto refill kinds of things, when you get to be about two weeks before your prescription's gonna run out, it's a good time to be thinking about calling and getting your refill and your pharmacy may hold that refill until it's time to refill it, but at least you're not gonna run out.
Joyce Griggs: Mm-hmm.
Alan Feren, M.D.: So I think that that's a very important aspect, and by all means, don't wait till the weekend. If on Friday night you see you, you only have one pill left for the weekend, it's gonna be very hard to get ahold of your physician to get the prescription authorized and get it filled. So you have to really stay on top of prescriptions.
Joyce Griggs: Mm-hmm. Yeah. I get it, too, with travel, you know, we really need to plan ahead. If in the middle of my travel, I'm gonna be running out and I'm out of the country, I need to figure that out in advance, and that you can do that with an insurance override. The other thing that I have found is that within the United States, I actually started going to a chain, a national chain to get my prescriptions because I did travel around the US so much so that when I was in Connecticut, my insurance is in New York, if I were in Connecticut or North Carolina, I could still get my prescriptions through transfers and then making sure that they had the right code because my insurer would allow for this.
Alan Feren, M.D.: Yes.
Joyce Griggs: It's just the right code into the system in order for them to be able to fill that prescription. So these are things also that can be done. And it does work out very well, especially like if you're traveling for extended periods of time, months at a time.
Alan Feren, M.D.: Yes.
Joyce Griggs: Yeah. Okay, great. Now I have another question about, about access, because let's say I'm put on a new medication. It's not as simple as it's on the formulary, the drug list of my insurer, right? Not every drug has this, but some drugs have some other things that are necessary before I can access them, is that right?
Alan Feren, M.D.: Yeah, I think what you are alluding to is something called step therapy which is a way that insurers are making sure that the drug that has been prescribed, even though it's on the formulary, but it's a more expensive drug, that other drugs which have the same type of activity against whatever the issue is that is being treated have been tried first. So in other words, you don't use a cannon to kill a flea. So if you've got a less expensive drug that's in a lower tier, they'll want you to try that first.
Joyce Griggs: Okay.
Alan Feren, M.D.: And it sometimes is more than one drug. It can be several attempts at different drugs.
Now, you can sometimes obviate the need for step therapy because if you have already tried that drug let's say it was prescribed a year or two before and it didn't work and now your current doctor said, well, we're gonna try this particular drug, and you try this drug and it gets denied. They want you to try the drug that you have already tried. Your physician can get an override for that. And just say that drug was not effective. And it has been tried, but it needs to be documented.
Joyce Griggs: Okay, so step therapy. Is this something that my doctor or nurse practitioner is gonna know about when they prescribe a drug for me? Or like, how does that, how do we find out?
Alan Feren, M.D.: They're gonna know about it because it's been a giant headache for them in the past. You'll not have been the first person that has been asked to try step therapy.
Joyce Griggs: Okay.
Alan Feren, M.D.: They will know about it and they'll be aware of it. Yeah. And they'll know what drugs will need to be tried first.
Joyce Griggs: And as you say, you know, it could have been something that I've tried a year ago or six months ago or whatever, and I know it doesn't work for me. So it's just another important reason, right, for us to keep track. If you don't use electronic medical records or if it was before you were on electronic medical records, it's important for us to keep track of these things and be able to advocate for ourselves and say, Hey, you know what, doc, I did try this once before and it didn't work and it was before I was seeing you or remember, or whatever.
Alan Feren, M.D.: Right.
Joyce Griggs: You know, whatever it is.
Alan Feren, M.D.: And, and not only if it didn't work, but if you experienced any adverse effects from it.
Joyce Griggs: Yes.
Alan Feren, M.D.: Cause sometimes we forget. And we are pretty much clued into allergies, but we're not necessarily clued into adverse side effects of medications. How people will confuse the two of them. So some, some person, you know, the most common allergy that people allude to is typically penicillin. And they say, I'm allergic to penicillin. Well, what happens when you take penicillin? Well, a true allergy to penicillin is not necessarily just a rash. It could be a major uh, incident where you have difficulty breathing and you're, you're choking and so forth. That's called anaphylaxis, an anaphylactic reaction. But some people will say, I'm allergic. What happened? Well, I had loose stools, I had diarrhea. Well, that's not an allergy. It's an adverse side effect from the medication.
Joyce Griggs: Yeah. It's important to know these things. And then besides step therapy, there's prior authorization too, right?
Alan Feren, M.D.: Yeah. Prior authorization lives in the domain of managed care. So in practice I used to call it "the mother may I" from the health insurer.
Prior authorization is before using a particular drug, the insurance company has to be notified. And the reasons for the need for that particular drug need to be documented by your health professional.
Prior authorization is typically for higher expense type drugs or newer drugs that have been just approved by the FDA, and there's not a lot of experience with them other than knowing that they are very expensive. So I would have the need to be aware that if I'm taking a newer drug that's on the market, that there is a pretty strong likelihood that prior authorization or frank denial of that drug would not be unexpected.
Joyce Griggs: And I guess getting back to our cost conversation, we could look to the manufacturers, right? If we really did need that drug, if there was just no other option for us, and our doctor was like, you really, I really want you on this, the manufacturers help with what they call copay cards, which help to keep the copays at a certain level and or other assistance programs. So these are things that we can always look into for non-Medicare, non-Medicare people, this is available to us.
Alan Feren, M.D.: And you can also always, for any drug, look for coupons online.
Joyce Griggs: Mm-hmm.
Alan Feren, M.D.: There are those, and they're valid at a lot of different pharmacy chains.
Joyce Griggs: Yeah.
Alan Feren, M.D.: So it's a good idea to really keep track of your medications and where you get them and how they're distributed to you. And you can always ask your doctor if your doctor is prescribing, let's say a tier two or a tier three brand drug, you can ask, is there another drug that I can take? So it's not just deferring to his or her judgment for the medication. I think it's if you're advocating for yourself fully, then to ask, is this drug absolutely necessary? And then ask if there is, in their opinion, if there is either another drug or is it safe for me to pill cut for this particular drug?
Joyce Griggs: Mm-hmm. Mm-hmm. Yep. These are great conversations to have, and I think you mentioned it, but I think it's worth repeating. You can also ask for samples, right? To try something first, to make sure that —
Alan Feren, M.D.: Absolutely.
Joyce Griggs: — that works for you before you spend money on a full prescription. A 30 day or more prescription.
Alan Feren, M.D.: So that takes me to another topic now that you've mentioned it, and that is, you know, I can't remember the number, but it's a pretty significant percentage of people who don't finish a prescription. And that's typically true for, for example, antibiotics. So you're feeling well after three to five days and you've got a 10-day course of medication that's been prescribed for you. And so it's in the cabinet. And so the next time you have something similar, take out that medication. Well, you really shouldn't be doing that, and particularly if you have children, and particularly if you've not placed those medications in a place that's safe. So I really want to reiterate the importance of safe storage of medications. But the medications that you don't take, don't save them at home. Take them and dispose of them. And places to dispose them are your local pharmacies, typically, oftentimes your fire department will accept them, but don't leave them lying around the house. I think it's very important.
Joyce Griggs: Also finish your antibiotics. I just wanted to finish that thought. It's so critically important to finish your course of antibiotics even when you're feeling better.
But, but it's really important, you know, that we're having this conversation about our ongoing conditions and our maintenance medications and how we can advocate for ourselves and really make sure that we are understanding the costs that are associated with them and what we can do to, to manage those costs. And I'll just ask you for any parting words before we sign off for this episode.
Alan Feren, M.D.: Well, I think my parting words are, advocate for yourself. Take care of yourself. Be aware when new symptoms arise and act on those symptoms. Make sure that you let your healthcare professional be aware that you're having them. In the era of having the electronic medical records, we're able to have a digital conversation with our physicians. But also note that in those digital conversations, they tell you it's gonna be three to five days before you have a response. So if it's an urgent or emergent situation, the EMR is not the way to communicate. That's the phone call.
Do your part to take care of your body. It's the only one you're gonna get this time around.
Joyce Griggs: Okay. Amen to that. Thank you so much, Dr. Alan Feren. Thank you so much for being with us, and we will be talking to you again soon. Thank you.
Alan Feren, M.D.: Great. Thanks for having me, Joyce. Always a pleasure.
Joyce Griggs: Thank you so much for watching, and before you go, please check out our blog. There's many detailed blog posts for you to check out there on this topic and others that will be important to you as you navigate through your healthcare. And if you haven't already, please subscribe because you will get on a regular basis in your inbox a knowledgeable friend who's gonna make it easier and simpler for you to deal with all of your healthcare needs. Also we have a resources page that's full of free and very important resources that you can take advantage of. So check out the blog, subscribe to our content, and check out the free resources page. Thanks again for watching. I'm Joyce Griggs for United States of Healthcare.