DRUG DISCOUNT PROGRAMS & TIPS
DISCLAIMER: This information is NOT exhaustive. Acceptance or use of any low income program or discount program cannot be guaranteed until a decision is made by the organization or agency running it. However, general guidelines, like the one below, can be very helpful when taken in context.
Changing to a Preferred Pharmacy or Mail Order
Years ago, all the Medicare drug plans and most of the Medicare Advantage plans set it up so you could save a little bit of money for each prescription if you use a preferred pharmacy over non-preferred pharmacies (both are in network). The key is, that little adds up quick since the average person on Medicare takes eight, yes eight, medicines. Also, some plans save significantly for each prescription, in which case it is ever more important to go to the right pharmacy to get the savings.
IMPORTANT NOTE: We repeatedly talk to our customers only to find out that they are using the wrong pharmacy even though we told them in the past which one to use. It is easy to forget but it cost people money unnecessarily. We think one of the main reasons is because, technically speaking, non-preferred pharmacies ARE in network, they are just not preferred pharmacies. As a result, if you call customer service, look online, or ask the pharmacy, they will tell you they are in network. But of course, it usually gets lost that you will charged more for each prescription because they are non-preferred. Please remember the correct list or ask. Also, preferred pharmacies can and do change which also creates confusion.
MAIL ORDER: Most people don't like mail order but many do it anyways because it often saves quite a bit of money, especially over the long haul. For example, some of our plans have $0 copay on T1 & T2 medicines. That really makes a difference. Almost all drug plans will at least do $0 copay on T1 prescriptions.
The trick is you MUST use the preferred pharmacy to get that price, and there is only one preferred pharmacy in any plan we have seen. Basically, each insurance carrier has their own mail order pharmacy that they own and you must use it or you get no savings at all compared to getting them at your local pharmacy.
Good Rx & Discount Cards
Good Rx & Discount Cards have transformed the landscape for getting prescriptions for those on Medicare. Just because you have insurance doesn't mean you have to use it. As a result, you can get some medicines from your insurance and some from GoodRx, even during the same trip to the pharmacy.
Using Good Rx is easy, just ask the pharmacy to apply it. However, every now and again they have an issue, in which case it can be smart to have the GoodRx app downloaded on your phone so you can pull it up and show them. If that doesn't help you can ask the pharmacy to use a different coupon (there are dozens of GoodRx-like dicount cards - which are really coupons - that can be used). If that doesn't work you can go to another pharmacy just for that one medicine. That is inconvenient, but for some, so worth it depending on how much your saving.
We have increased out recommendation alot for GoodRx over the years to the point where we probably recommend it for one or more medicines to 40-60% of our customers who have drug plan.
Be careful to ensure you dosage and frequency (# of pills) are correct before you price it on their app. You can also call us or go online to GoodRx.com. Either way, it tells you which pharmacies have it and at what price. Walmart is often the lowest but, at the same time, other pharmacies are often lower too. That is why it is best to check before you use GoodRx. Many times the price is significantly lower depending on the pharmacy you use.
Remember, when you use GoodRx, that is "off the map" of your insurance. That means there is no deductible or donut hole. Conversely, it also means the money you spend on GoodRx does NOT apply towards your deductible.
Pharmacy Discount Lists
Most chain pharmacies have 'in house' drug discount programs available to anyone, regardless of their insurance, for their prescriptions. This is a list of commonly used generics (and some brand at certain pharmacies) that have reduced prices to a more affordable amount. You need a prescription, but you don't need insurance to get this price. In fact, when you use a pharmacy discount list, you not using insurance at all (let's call it a non-insurance price). However, even with your insurance you can get the drug discount price if you ask for it.
One small problem is that you get a fixed price for a certain number of pills. However, with your insurance, you get a fixed price for a 30 day supply, regarless of the number of pills required. For example, if you take Lisinopril 5 mg 3/day and your copay on your insurance is $5 but the copay for Wamart's $4 list is, well, $4. Logically, you should get it on the Walmart $4 list but, since you only get 30 pills the price would actually be $12 ($4 x 3). So it is lower cost to get it on your insurance for $5. If you are not paying attention, especially when your buying other medicines at the same time, you could easily miss this. Check the number of pills that are provided on any pharmacy discount list (it varies and can just as easily be 60, 90 or more as compared to only 30)
WALMART'S $4 LIST: The most well known is Walmart's $4 list, which has changed over the years to be a mix of $4, $9, $15, and $24 medicines. They have technically changed the name to Walmart Rx Program, but most everyone still knows it as the $4 list. It is two pages worth of commonly used generics that have helped a lot of people. Walmart generally automatically gives you their discounted price if it is lower than your insurance, but we recommend paying close attention at the counter to ensure you get the lowest price.
SAM'S CLUB Rx SAVINGS FOR MEMBERS & EXCLUSIVE PRICES FOR PLUS MEMBERS:
Most people don't know this, but their exlusive list for PLUS members is much longer than Walmart's $4 list. They advertise 600+ Generics on it and 2+ pages of brand names. Be careful, they actually have two lists, one for regular Sam's Club members and one for Sam's Club plus members. The plus members get a deeper discount, even some for totally free. Wow! For example, Lisinopril 10mg 1/d (30 pills) is $4 for regular members, but $0 cost for plus members. All in all, you are more likely to get a better deal at Sam's than Walmart, but you need a membership for Sam's which requires annual dues.
UNITED SUPERMARKETS/ALBERTSONS: They cancelled their discount program a few years ago, but they often have good prices on GoodRx and other coupons. Instead, they have been known to encourage their customers to sign up for Singlecare, which is a coupon program just like GoodRx.
CVS ExtraCare PHARMACY & HEALTH REWARDS: With this, you get credits for prescription purchases you make that are converted to pharmacy discounts you get on future purchases & other rewards like discounts on CVS branded products. They also offer other rewards. You have to enroll in the ExtraCare program to get the savings but it has no cost.
We don't know a lot about CVS's programs because they don't seem to publish a defined list of discounted medicines, but we have heard people say they like it and we can't recall any negative feedback.
WALGREENS' PRESCRIPTION SAVINGS CLUB: Similar to CVS in that you get other rewards as well, like discounts on Walgreens branded products, but this one is unique in that you actually pay a $20 annual fee ($35 for a family) and you get a card to use at the pharmacy. They publish tier 1, 2, 3 pricing at $5, $10, and $15 and then label their meds in tiers. They publish a list and it does have quite a few medicines on it, whereas Walmart's $4 list is significantly smaller.
KROGER SUPERMARKET: We have gotten good feedback about Kroger, but it is difficult to find clear info about their program. They make it seem like they just use a GoodRx-like card called the Easy Drug Card, except for when you check common, low-cost meds on easydrugcard.com, they come out more expensive that I know them to be. Also, they are priced wrong at multiple pharmacies. I think the best thing is just to as them for a coupon at the pharmacy counter.
Patient Assistant Programs (PAP) (Manufacturer Programs)
This is the one of the best program you can get since it lowers the cost to $0 or near $0, it applies to brand named medicines which are notorious for being expensive and hard to get lowered, and it works well once you get it going. As you can see, usually the actual manufacturer sends the medicines sent directly to you, but sometimes they send it to your pharmacy or doctor and you pick them up (at the same low price). Often, your doctors office or a pharmacist can apply on your behalf. What many people don't know, and I believe this causes many to miss out on this wonderful program, is that you can apply for yourself just by going to one website, RxAssist.org, that will link you to any PAP program.
Again, we encourage you to check RxAssist.org and look up your brand name medicine to see if they have a program for it. When you go to the website, you must click the gold circle labeled "Learn More" on the right under the patients section, then type your medicine in the search bar. Once there, you will see a list of the qualifications to enroll. Don't trust this list and call the number above and ask them about the qualifications to see if you are eligible. The qualification list on the website is correct sometimes, but you need to be sure since brand name meds are so expensive there is quite a bit of money you can save if you get approved.
Assuming you appear to qualify, there are two links on Rxassist.org, once for the specific program website and one for the application. I would ask the customer service representative you are speaking with to send you one, or to clarify that the one(s) online are the most recent version. These applications can be annoyingly lengthy, which is one reason more people don't have these programs, and it is can be frustrating to have to do it twice because you had and old version of the enrollment form.
You generally have to enroll in these programs once per calendar year. Some of them require you to spend a certain amount of money (usually 3%) of your household income on all your medicines combined for the calendar year before they will enroll you. You can usually get a summary of that at any time printed out from your pharmacy and include that with your application once the total reaches the 3%. That may seem like a pain to some, but getting your expansive brand name drug for free the rest of the year is so worth it.
DELAYING OR AVOIDING THE DONUT HOLE FROM A PAP: Many people have enrolled in these programs only to find that they hit the donut hole later in year than normal, or not at all. This is a noteworthy side benefit. Since any medicines filled by a PAP is 'off the map' of your insurance, then the total cost of the brand name medicines DO NOT count towards the donut hole. Since brand are so expensive in most cases, that lowers your total drug costs which is what is used to determine when and if you go in the donut hole. For example, if you remove one brand medicine from your insurance that has a total cost of $500 (which isn't that uncommon), that removes $6000 ($500 x 12) from counting toward your donut hole. Or even if you enroll in the PAP in April or May after you have reached the 3% threshold, you just removed $4000 or $4500 from counting towards the donut hole. Depending upon your other drugs, this translates into significant savings by going into the donut hole months later (or not at all) than you would have. Let me repeat, going into the donut hole in October or November compared to June or July, for example, is a major savings not to mention the frustrations and stress of having to deal the increased costs of the donut hole.
Extra Help With Medicare Prescription Drug Plan Costs
Samples from Your Prescribing Doctor
This technique is usually something the doctor brings up during an office call. However, there is no reason why you can ask for them at any time, especially if your in pinch and only need them temporarily. Some doctors can provide them on a semi permanent basis in certain circumstances.
This only applies to brand name medicines that the drug manufacturer is promoting by providing free samples to the doctor so they can in turn promote it by giving it to you for free for a few months and then you buy it on your own.
It is best to review your coverage, including the possibility of a deductible, of the sample your getting so you can know the cost once the samples get cut off.
SAMPLES & THE DONUT HOLE: Many people hit the donut hole late in the year in November or December and have to pay alot more for their drugs just for one or two fills. In that scenario, if they could get just one or two samples a year of one of their expensive brand name medicine(s), then they might hit the donut hole later or not at all (the later you hit it, the cheaper it is). We recommend just explaining that to your doctor and ask for samples. Help is often only available for those who ask. Even if it causes you to go into the donut hole in October instead of September, that saves you money since the donut hole increases costs on all your meds, not just the expensive ones that primarily drive you into it.
Substitutions: Generics, Generic Alternatives, & Brand Substitutions
It is widely known that generics are lower cost than brand (actually, there are some unusual cases where the generic is similar or higher than brand). However, generic alternatives substitutions can be overlooked. This is where your insurance covers 3 or 4 medicines that do the same thing (in the same therapeutic category) but 1 or 2 are in a lower tier than the others. Since the lower the tier the cheaper, you ask your doctor if you can substitute one with a lower tier if you happen to be taking one with a higher tier. Some people stress this with their doctor immediately upon being prescribed a new medicine that they will continue taking for a long time (called a maintenance medicine).
BRAND SUBSTITUTIONS: Most brand name medications are tier 3. Since most Medicare drug plans charge a set copay (eg. $47 instead of variable cost of 40%), then most brand name medicines are the same price to the customer. However, when it comes to calculating the donut hole, Medicare doesn't use the price the customer paid, they use total price which varies heavily in most cases. For example, insulin is $47 whether you get the pen or the vial. But the total cost is usually around $250 to $300 for the vial or $450 to $500 for the pen. The pen maybe more convenient but now you are going to fall in the donut hole 2-3 months earlier than you would have if you had used the vial. Of course, that significantly raises your drug costs for ALL your meds for longer in the year. In the end, you can't look at the price you pay, but instead look at the total price it costs. This is available every month on your drug summary mailed or email to you by your insurance carrier (not Medicare itself). There are countless examples of this for substituting one brand for another to reduce total drug costs to delay or perhaps avoid the donut hole.
Insulin Senior Savings Program
This program is not well known and is underutilized in our view. However, it can really help people who use certain insulin on the program, which varies insurance carrier to carrier. The only way to know for sure is call customer service for your drug plan and ask them what insulins are on their approved list.
BENEFITS: Select Insulin will cost only $35 throughout the year, regardless of your deductible or if you fall in the donut hole or not. Again, if your plan has a deductible, it is waived for the insulin (not for any of your other drugs).
The trick to this is you must use the appropriate pharmacy which doesn't necessarily correspond to the normal preferred pharmacies in your network for your particular plan. For example, if a Medicare Advantage plan uses Walmart as a preferred pharmacy, but when we call the plan they told us we can't use Walmart for the Insulin program, but United Grocery Store was ok.
Also, you must tell the pharmacy that you want to bill it separately as "SENIOR SAVINGS MODEL". That is a bit tricky, but know that the pharmacy is not billing your insurance as normal. Make sure you tell them the exact words, "SENIOR SAVINGS MODEL".
VA Pharmacies & Medicare Non-VA Pharmacies
People who are eligible and registered with VA can get their meds through VA or through non-VA pharmacies from their Medicare drug plan. The advantage is that you can get your meds through whichever is cheaper. It is common for people to have a doctor(s) through VA and doctor(s) through Medicare.
The copay with VA varies, but in many cases it is quite low for brand or even $0 for brand and generic. Again, whatever is cheaper, go with. And you don't have to cancel one or the other, you just have both (VA has no monthly premium).
A big benefit here is that since people tell me alot that VA is very limited on covering brand name meds, then they can possibly use their Medicare drug plan for any brand name meds that VA won't cover.
Also, if they get prescribed a medicine from their Medicare doctor, and that med is available from VA for lower, they may not have time to make an appointment with VA, get to the appointment, then wait for the med to come in the mail. So having a drug plan on Medicare gives the advantage to get that med quickly at the local preferred pharmacy for your drug plan.
One negative worth noting: sometimes people on VA recognize that their maintenance meds are lower cost through VA, so they make an appointment to get them represcribed by VA, and the VA doctor wants to prescribe different meds. I have heard of this as a problem and most people just let the savings go and keep getting their medicines from non-VA pharmacies. This doesn't always happen, but it is a potential pitfall.
Unfortunately, all Medicare drug plans cover half or less medicines than typical group insurance or any major medical insurance you can get when your not on Medicare (generally under 65). Put another way, their formularies (list of covered drugs) are really thin. This is true even amongst the most expensive (called enhanced) plans. This means it is far more common for someone on Medicare to be prescribed a medicine that is not covered than someone who has insurance that is not on Medicare. Worse, people on Medicare get prescribed, on average, far more medicine than those not on Medicare. It is easy to see the problem.
One way to solve this is to know how to potentially get a medicine covered that is not on your formulary. Called a formulary exception, meaning the insurance carrier will cover the medicine just for you for one calendar year (or the remainder of the calendar year). There is no guarantee it will be covered well (meaning at a low tier), but it is worth trying and this technique helps alot of people each year.
REQUESTING A FORMULARY EXCEPTION: The easiest way to do it is calling your doctor's office and ask them to initiate it. Or you can call the number on the back of your drug card and tell customer service you want to initiate a formulary exception. In some instances, pharmacies can even initiate it. Either way, the process is the same. The insurance carrier will ask your doctor why you need this uncovered medicine and you doctor will give a reason why you need it and your insurance carrier will decide based on that and other guidance to grant the exception or not. It seems to us that most of the decision is based on how good of an answer the doctor give for your need for that medicine (but I can't guarantee that). Still, it is best to let your doctor know you are going to request the exception or just let them do it so they can be prepared, rather than rushed, to give the reason. A formulary exception must be requested once per calendar year except in unusual cases.
There is another type of formulary exception that is used to reduce the tier of an already covered medicine, thereby lowering the copay. This is better known as a tier exception but it is largely unknown and therefore not used often. We have not seen a lot of them be granted, but I think people should try it more often.
Medicaid Drug Coverage (or lack of Drug Coverage)
There are two major types of Medicaid (let's call that traditional Medicaid). Medicaid for people who don't have insurance and Medicaid for people on Medicare (often known as QMB, Medicare Saving Program, SLMB, QI, Dual, Full Dual, Dual Eligible, etc).
Traditional Medicaid for those not on Medicare generally covers prescriptions (more often yes). However, Medicaid for people on Medicare does not cover medicines. Years ago it might in very rare cases, but we haven't seen that in many years. The reason why this is not a problem is because anyone who get Medicaid for people on Medicare automatically qualifies for Extra Help which means they can get a Medicare Prescription Drug Plan for $0 premium or reduced premium. In fact, if you don't select a plan, Social Security will automatically enroll in one. We have encountered many, many people over the years who didn't know this. They had coverage and didn't realize it, or they had coverage and weren't using it properly because they didn't realize they had Extra Help.
The way to verify if you have Extra Help is to call us so we can look it up, call your drug plan, or call Social Security, Medicare or Medicaid (your state's health and human services office). The way to verify if you have a drug plan, or what drug plan you have, is to call us and we can look it up, pay attention to what insurance carrier is sending you monthly drug summaries, or call Medicare.
Walmart's NO PRESCRIPTION REQUIRED Insulin Program
This one is really helpful. Walmart literally has limited insulin available over the counter for a reasonable cash price. The only problem is it is only for select insulins, Novolin N & R, which is generally a short-acting insulin. However, they are in the process of adding a long-acting one.