Why is my medication so expensive?
Unfortunately, the answer is often much more complicated than the price of the medication itself.
When your doctor prescribes a medication, we choose it based on what we believe is medically appropriate for you. We do not determine what your insurance company will cover, what tier a medication is placed on, what your copay will be, or what price the pharmacy will charge you.
A major part of this system involves companies called Pharmacy Benefit Managers, or PBMs.
PBMs are companies that work between health insurance plans, drug manufacturers, and pharmacies. They help administer the prescription-drug portion of many insurance plans.
Depending on your insurance arrangement, a PBM may influence:
· Which medications are included on your plan’s formulary
· Which medications are considered “preferred”
· Whether you must try another medication first, known as step therapy
· Whether a medication requires prior authorization
· Which pharmacies you are encouraged or required to use
· Your copay or coinsurance structure
· How much a pharmacy is reimbursed for dispensing a medication
· Negotiated discounts and rebates associated with medications
This means two patients can receive the exact same prescription from the same physician and pay dramatically different amounts depending on their insurance plan and pharmacy benefits.
“My insurance covers it. Why is it still so expensive?”
Insurance coverage does not necessarily mean that a medication will be inexpensive.
Your cost may depend on your deductible, medication tier, coinsurance, pharmacy network, quantity limits, and other provisions of your specific plan. A medication can technically be “covered” while still leaving you with a substantial out-of-pocket expense.
In some situations, the cash price, a manufacturer savings program, or a legitimate prescription-discount program may even be less expensive than using insurance.
“Why did my insurance deny the medication my doctor prescribed?”
Insurance companies and PBMs maintain their own formularies and coverage requirements.
Your physician may determine that a medication is medically appropriate, while your prescription plan may still require:
· Prior authorization: Your doctor’s office must submit additional clinical information before the plan will consider coverage.
· Step therapy: Your plan requires you to try one or more preferred medications first.
· Quantity limits: Your plan restricts how much medication it will cover during a particular period.
· Formulary exclusion: Your plan simply does not include the medication in its covered drug list.
These are insurance benefit decisions - not decisions made by your physician’s office.
“Can’t my doctor just call the insurance company and make them cover it?”
We wish it were that simple!
Our office routinely provides medical records, diagnoses, previous treatment information, documentation of medication failures, and other clinical information requested during the authorization process.
However, your physician cannot require or force an insurance company or PBM to pay for a medication.
Even when we strongly believe a medication is appropriate, coverage may still be denied.
“Why doesn’t my doctor’s office know what my medication will cost before prescribing it?”
Every insurance plan is different, and formularies and pharmacy benefits can and frequently do change.
Your physician does not have access to all the contractual information that determines the final price you will be charged at the pharmacy.
Even patients with the same insurance company may have completely different prescription benefits because their employers or individual plans purchased different levels of coverage.
“What can I do if my prescription is unexpectedly expensive?”
Before assuming that nothing can be done, we recommend:
1. Ask the pharmacist why the price is high. Determine whether the medication was actually processed through your insurance and whether the cost is related to a deductible, copay, coinsurance, or non-formulary status.
2. Contact the number on your prescription insurance card. Ask whether the medication is covered, what tier it is on, and whether a preferred alternative is available.
3. Ask about alternative pharmacies. Your plan may have preferred pharmacies where your cost is lower.
4. Ask about manufacturer assistance or savings programs. Some medications have programs for eligible patients.
5. Compare the insurance price with the cash price. In certain circumstances, paying without insurance may cost less.
6. If an alternative medication is required, let our office know exactly what your insurance company recommends. We can then determine whether that alternative is medically appropriate for you.
Please understand that we are on your side.
We understand how frustrating it is to leave your doctor’s appointment expecting to begin treatment and then discover that your medication costs hundreds - or even thousands - of dollars, requires authorization, or is not covered at all.
Our team will make all reasonable efforts to help navigate these issues and provide the clinical documentation required when appropriate.
At the same time, our office does not control your insurance company’s formulary, PBM policies, deductibles, copays, pharmacy pricing, or final coverage decisions.
We ask that you please direct frustration regarding medication pricing or insurance coverage toward the appropriate insurance or pharmacy-benefit organization rather than toward our clinical or administrative staff.
Our responsibility is to recommend appropriate medical care and advocate for our patients when we can. The insurance company’s responsibility is to determine what benefits it has agreed to provide under your particular plan.
Healthcare has become extraordinarily complicated. Understanding which part of the system is making a decision can make these situations a little easier to navigate.