Shop smart at the pharmacy counter
Steve Wexler has experienced the trouble of finding affordable prescription drugs.
A few years ago, the 70year-old Plymouth, Minn., resident opted to cut short his prescription for Eliquis, a popular blood thinner, rather than pay nearly $1,000 out-of-pocket for his final month on the medication.
Smart shopping can’t always tame high costs like that, Wexler said, yet he remains a strong advocate for health care consumers trying their best to be savvy when it comes to their prescriptions.
He’s found significant savings through the years by choosing the best health plan, comparing prices at different pharmacies and using discount card programs.
“As a consumer,” Wexler said, “you’ve just got to be your own advocate and continue checking and shopping around.”
Spending on prescriptions is once again taking center stage in the nation’s never-ending drama with escalating health care costs.
Last fall, the New Yorkbased consulting firm Mercer reported the average increase for employer health plan costs exceeded 5 percent in 2023 and will likely do so again this year, a second consecutive year of faster growth.
Prescription drugs have been the highest-growing category of expense for several years, according to Mercer, and the rate in 2023 pushed up even higher to 8.4 percent in part because of the growing popularity of drugs for diabetes and weight loss, known as GLP-1s (a popular one is Ozempic).
“Medications don’t work if you don’t take them,” said Cathy McLeer, state director for AARP Minnesota. “Research has shown that the main reason that older Americans don’t fill their prescriptions — or they end up taking a lower dose than was prescribed for them — is simply because they can’t afford to . ... We advise people just to be good consumers, and do their homework.”
Here’s what you need to know about how to save money at the pharmacy counter:
The first step for most people trying to handle drug costs is to understand the details of their insurance.
Medications are typically assigned to one of three categories — generic, brand or specialty — and then listed on a formulary that specifies which drugs the insurance covers. Patients pay more or less out-of-pocket depending on the formulary tier where a covered drug lands.
Tier 1 drugs are often called “preferred generic” medicines and have the lowest copays. “Non-preferred” generics follow in tier 2. From there, out-ofpocket spending generally increases as patients access “preferred brand” drugs in tier 3, “non-preferred brands” in tier 4 and specialty medicines in tier 5.
In higher tiers, “co-insur
ance” fees, which typically cause more pocketbook pain, can replace copays. So using generics when possible is one way to save.
Another tip is to stick with in-network pharmacies, since copays and coinsurance usually are higher when you go outof-network. Finally, patients usually pay less when receiving a 90-day supply of drugs, often via a mail-order pharmacy.
All these details can vary by health plan, of course, so check your own plan documents.
“You need to understand your plan’s benefits … to understand what drugs are covered and how they’re covered,” said Patrick Mitsch, a vice president for pharmacy at UCare, a Minneapolis-based health plan.
If out-of-pocket costs through the health plan are too high with a particular medication, Mitsch said, patients should ask their pharmacist and/or doctor if there’s an alternative drug with comparable efficacy that has better coverage. When there’s no alternative for a recommended drug that’s not on the formulary, he said, patients might ask their insurer for a special authorization.
In some cases, health care providers are aware of or can help patients access special programs that can help with high costs, said Jesse Breidenbach, vice president of pharmacy at Sanford Health, a South Dakotabased health system.
“I would say almost all the time, there’s a path toward getting to a point where the medication becomes affordable, maybe at little or no out-of-pocket cost,” Breidenbach said.
Claire Henn, 77, of St. Paul, Minn., said a program at Allina Health currently covers sizable co-payments for an expensive medicine she receives via infusions every month for rheumatoid arthritis. She’s thankful for the medicine as well as the program: A few years ago, Henn said, she had to stop taking a different rheumatoid arthritis drug when monthly outof-pocket costs jumped from $60 to $1,400.
“My rheumatologist recommended it,” she said of the Allina program. “It’s a life-saver.”
Whenever possible, patients should check in advance to see what sort of coverage they’ll have for their medicines with the various health plan options they can select. It’s worth watching for changes, since they can occur regularly.
Wexler said he’s annually switched prescription drug plans during each of the five years he’s been on Medicare to find the best fit between the drugs he’s taking and the benefits different insurers offer.
There are certain situations where consumers at the pharmacy counter decide to bypass their health plan benefits.
Sometimes, patients run into such snags like prior authorization rules or having to argue with their insurer for coverage, so they opt to simply pay cash in order to access the medication now, said Matt Anderson. Anderson is a member of the state’s Prescription Drug Affordability Board, a new watchdog group the Minnesota Legislature created last year.
In other cases, a prescription might be cheaper without using coverage because the required outof-pocket spending through the health plan is greater than the pharmacy’s cash price or price through a discount card program.
“If you don’t use your benefits, the drug cost you pay doesn’t count toward your deductible,” said Anderson, who is also a senior lecturer at the University of Minnesota’s school of public health. “So the near-term savings of paying cash could be offset because it takes longer to satisfy your deductible.”
For people who know they’re not going to hit their annual deductible, cash purchases might result in savings, said Jon Hess, a health care consultant in St. Paul.
To scout the best deals using cash, consumers can look at the price they’d pay via the Mark Cuban Cost Plus Drugs Company or prescription discount card programs, such as GoodRx. Prepare to do some homework, though, because there’s been a proliferation of discount card programs in recent years, including recent offerings from OptumRx (a division of Minnetonka-based UnitedHealth Group) and CarelonRx (part of Indianabased Elevance, which runs many for-profit Blue Cross Blue Shield health insurers across the country).
“In November, Walgreens launched the Rx Savings Finder, which allows patients to access multiple third-party discount cards including GoodRx,” analysts with BofA Securities wrote in a January report. “The most likely winner from these changes could be the consumer through lower pharmacy prices.”
After making cash purchases, consumers with insurance should check if they’re eligible for health plan reimbursement, said Hess, who previously ran a startup company that helped patients with medical billing problems.
For patients with nongovernmental insurance, Hess said, another option is financial and copay assistance programs run by pharmaceutical companies. The trade group for drug manufacturers has launched a website called Medicine Assistance Tool (MAT) with information on these programs.
Established patients at a subset of clinics known as federally qualified health centers can gain access to prescriptions at lower costs through a special agreement between the manufacturers and the federal government. There are more than a dozen of these health centers in Minnesota.
“I would personally encourage somebody having problems paying for their medications to check out a community health center because we might be the answer that they’re looking for,” said Ken Nelson, a pharmacist with St. Paul-based Minnesota Community Care.
A final option is ordering medicine from pharmacies in other countries, such as Canada. While these prices are sometimes lower, Nelson questioned whether the savings are worth the hassle for patients. Mitsch of UCare added health plan reimbursement is very uncertain for purchases from Canadian pharmacies.
For Medicare patients, there’s good news on the horizon when it comes to drug costs, Mitsch said. Starting next year, Part D benefits will become significantly richer, with a cap on out-of-pocket spending on drugs at $2,000.
Longer term, the federal Medicare program is beginning to negotiate prices for a limited number of medications, including Eliquis. The first negotiated prices are effective in 2026. Democrats promise this will bring big savings for both seniors and the federal Medicare program, while manufacturers have warned it will stifle innovation by cutting funds for research.
Even as the drug cost landscape is changing, pharmacists say some patients will continue to confront big expenses.
For a patient taking prescription drugs on a chronic basis, the average annual cost of therapy in 2020 for one widely used drug reached more than $26,000, according to research AARP published in January. The annual cost of therapy would have been more than $14,000 lower in 2020, AARP said, if price changes since 2006 had only kept pace with the rate of general inflation.
Drug companies argued this study paints a misleading picture of drug costs trends by not factoring in how pharmacy benefit managers (PBMs) and other middlemen have been ballooning what patients pay. The Pharmaceutical Research and Manufacturers of America (PhRMA), a trade group, pointed to a different study showing net prices for brand medicines remained flat in 2022 after accounting for rebates and discounts PBMs and insurers collected.