¶ Understanding High Prescription Costs
You're listening to Life Kit from NPR. Hey, it's Marielle. You ever get to the pharmacy to pick up some drug that your doctor says you need and you wait in the line? Surrounded by people who are coughing and sneezing. And you're hungry because you just got out of work. And you're ready to be home already. And then the pharmacist rings up your drug. And it's going to cost... Pardon me? How much?
See, you expected it to cost 20 bucks, but instead it's 170. Or 500. Or 1,000. And you're like, you know, what do I do? What am I supposed to do? Dan Weissman is the host of the podcast An Arm and a Leg. It's a podcast about why health care costs so freaking much and what we can maybe do about it. Earlier this year, Dan heard a story from Wisconsin about a young guy named Cole Schmitnacht. Who had asthma.
And showed up at his pharmacy one day to get the inhaler that he used to just kind of maintain. And he'd been using it for years. And they were like, okay, that's $500, which he was not expecting. I think he was expecting to pay something like $70. And he just walked away like he had no idea what to do. And within a couple of weeks, he had a big asthma attack and he died.
His parents filed a lawsuit against the pharmacy and the pharmacy benefits company. Because they were like, somebody should have told him that like this specific medicine. The deal had changed under his insurance and it was no longer covered. It was going to be $500. But there's essentially an equivalent inhaler he could have walked out with for a price that would not have shocked him. And had somebody told him that.
He'd be alive today. And so as we gathered these stories, I was like, this is essentially the scenario that we're wanting to intervene in. We don't want this to happen to anybody. Everybody should know the questions to ask, the things to try, because in his case, and in a lot of cases, there is something you can do. Dan and his team have asked their audience to share their experiences, their tricks, their hacks for getting around the high cost of drugs.
They're all workarounds, right? They're all like, what's a little patch I can put on this extremely broken thing? There's no single direct path to like, this is the thing you can do. And a lot of times what you're going to do involves a lot of work. After talking with lots of people, they ended up with a kind of order of operations, a checklist. What to do when your prescription costs way more than you expected. On this episode of Life Kit, I talk to Dan about that list.
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¶ Immediate Steps: Check for Discounts
OK, Dan, let's start at that moment of sticker shock when the pharmacy tells you how much this drug is going to cost you. What is the first step? The first thing to do is to be like, wait, really? Like, are you sure? Is there some kind of mistake? Like, this happened to me one time. I went into the pharmacy. I had a prescription for an old line prescription drug. And the pharmacist was like, that's going to be $400. And you said, no, no, thank you. I said, really? Recalculate, please. Yeah.
And I was like, wait, I think my insurance changed. Do you have my new insurance? And they were like, actually, under your new insurance, it's $0. So just check for simple errors. Ask. Like, could you check with my provider? Is there like something misspelled? Is there something, you know, easy with the insurance that can be fixed? What else can you ask the pharmacist while you're there? There can be other questions like your doctor.
It was like, I want you to take this twice a day. So I'm prescribing you 60 tablets of five milligrams. And it turns out the pharmacy wants like four times as much for that. And the pharmacist could be like, you know, I could give you 30, 10 milligram tablets and there's a pill cutter over there and you could like.
solve this there's just things your doctor may not know about how you're going to be charged for a particular thing that happens all the time the next question is like and you ask the pharmacist first is like hey Is there like a discount for this? Is there like a coupon you could look for? And, you know, again, I've been you may have had this experience, too, that some farmers have been to the pharmacist like, oh, wait, let me check. I think there's a coupon for this.
And they just tell you, oh, yeah, I can give this to you for something much more reasonable. But they may or may not do that. They may or may not be able to check. But you have in your pocket some answers, right? You can basically just open up your phone, go to Google and. and put in the name of the drug you're there to get and like discount or coupon. This is wild to me.
When I first found out – I use them now all the time. But when I first found out that there were coupons for pharmaceutical drugs and they can lower the cost significantly and they're just available online. Like you don't have to – subscribe or pay to get access to them but it's a if you know you know thing right yeah
Yeah, it's just there. And there's kind of two flavors, right? I mean, you'll probably you do this Googling, you'll probably get a result from a site like GoodRx, which people are probably familiar with. And it will tell you, like, there's actually you could just pay cash for this. And this is super discounted price. And we should just say.
Rx has been a sponsor for NPR, but you found out about them through your own reporting, right? Yeah, exactly. And yeah, you don't have to sign up for anything. You just like click a thing and it. Shows up on your phone and there's a code you show to the pharmacist and they're like, great, here it is for a price you could probably afford. When I showed up at the pharmacy and was told my drug would be...
$400. I was like, I've heard about this site, GoodRx. And it was pretty interesting because it showed your pharmacy is asking for $400 for this. If you use our coupon, you could pay $100. And I was like, that still seems like an awful lot. And they're like, Walgreens wants $100 for this. And CVS wants $75. But Mariano's, which is a local grocery chain with a pharmacy in it, they'll sell it to you for $20. Costco, $20. Walmart.
$15. And this is all what you saw on GoodRx? These are discounts that GoodRx has worked out, but it's different at every pharmacy. So you mentioned that pharmaceutical companies will often offer coupons as well. How do you go about finding those? You Google the name of your drug and coupon or discount. That is the most direct way. And if it's there, it's probably going to show up. I mean, GoodRx may have a link to it also.
They're not hard to find. The manufacturers want them to be easy to find because they want you to use them. Are there any caveats here when it comes to using coupons? The first caveat is like not every drug that you would want a coupon for. has a coupon you can use. And another one is the coupon may not make it really affordable for you. The coupon may be like, this drug that they're going to charge you $500 for is now just $100 for you. And you may be like,
Thanks, but $100 is still more than works for me. And then there are parts that are more particular to you. One is you actually have to have insurance for this to work because the strategy on the drug companies part here is they're going to get the insurance company to pay them once they've.
giving you a discount, there's still money left over for them to be paid by the insurance company. So if you don't have insurance, there's no point to them giving you this discount. And not all insurance works with it. Specifically, if you have... Insurance is basically backed by the federal government, like Medicare or TRICARE or the VA. There's what are called anti-kickback laws written that basically mean you can't access these deals. So that's not great.
Finally, your insurance company may put up roadblocks. And the basic idea is the insurance company sees the pharmaceutical company's game. They're like, I don't like that. And I'm going to make it so that. Dan can't use your coupon. Or if he uses it, he's still got to pay his big deductible. He's still got to lay out tons of money and cash before I start kicking in for this. Fun. It is super, super, super annoying. I mean.
Annoying doesn't cover it, right? There's just no words. Yep. Okay, so we tried seeing if there was a mistake. And then we tried looking for coupons. Yes. The next step is to ask your provider.
¶ Doctor's Role: Alternatives and Samples
if they can help. Yes. So we learned about this. We kind of distilled this playbook partly from talking to this woman, Jeannie Chamberlain from North Carolina. So her husband got a prescription. They took it to the pharmacy and... It was $1,200 for a 14-day supply. Wow. So, you know, she did the first things. She went to Google and she was like, is there a discount here? Is there a coupon here? And Google was like...
Well, good news. Yes, there's a coupon here. But bad news with the coupon, this $1,200 thing is $800. And Ginny was like, that's not going to work. So on to the next step. And so we did what I tell people to do. We went back to the doctor and said, is there something else? A lot of the time, yeah, there is. You can ask the pharmacist or your doctor, is there an alternative version of this medicine that could work for me?
And your pharmacist may say, oh, yeah, right. So this particular asthma inhaler, it's no longer covered by your insurance. It's going to be five hundred dollars. But there's one made by a competing company that like works for most people. And.
It looks like I could give it to you for like 20 bucks. But you want to loop in probably your provider in most cases to say like, is this other one? Is there some reason I shouldn't take this other one? Because sometimes there is. Sometimes your providers can be like, well.
Because you're on this other thing that I've prescribed you, you probably shouldn't do that one. Or, well, I've had bad experience with it. But like many, many times for medications that are super common, it's just a random quirk that like... This essentially equivalent medicine is being priced really high for you under your insurance, but this other one, it would be totally available for cheap.
After the break, we talk about what to do when there is no alternative. And Dan shares more tips. Okay, we're back. Dan, what can you do when your doctor says there is no other drug for you to take? Then you've got a couple of steps to follow. One question is like, does my insurance just not cover this at all? Or are they asking what's called a prior authorization?
Meaning they need your doctor or provider to like write them and tell them my patient here needs this specific drugs. Here are the medical reasons that other alternatives are not going to work for this patient. I need this one. And your provider should be familiar with that rap and should go ahead and write whatever letter they need to write. But that can take time, right? Your doctor may be like, I'm going to write that letter for you, but I'm going to tell you they're going to want 14 days.
to get this resolved. And you're like, I need this right now. And when you get to the point where it's like, we got to fight with the insurance company, this is where our listeners really came through. And this tip came from a kind of surprising... place because the person who called it in is a pharmaceutical sales rep. His name's John. John requested that we use just his first name because he's not authorized to speak to the media about this kind of stuff. I love it when I hear stories of...
of average people just sticking it to the insurance company. And it's nice when the patient wins because they don't get a lot of wins. I note he said the insurance company, not the pharmaceutical company. Yeah, that's true. That's true. He loves average people sticking it to the other guys. But OK. I think of these companies, the pharmaceutical companies and the insurance companies and the big providers.
I think of them all as sharks. And they're each trying to say like, ah, I hate that shark. That's a bad guy, that shark. But like, they're all just sharks fighting each other. And what does that make us? The like little minnows? Yeah, we're the food. We're it. They're all fighting over who gets to eat the most of us. Yeah. Yeah. It's such an honor to be fought over by these guys. But so what John said was like, this is actually a place where someone like me can help you. He's like.
You know, I carry around samples. I have free samples of things. And this is kind of what they're useful for, right? That like your doctor may have on his shelf samples of this thing. You basically ask your doctor, Doc. Do you have or can you get some samples of this medicine for me? Then you have the medicine you need while you and your provider are waging this fight with the insurance company to get your medicine covered. Okay. So you go to your doctor, you say.
Got any samples? Yeah. Can you give me enough to tide me over for two weeks? Yeah. Or however long it takes. Okay. Well, let's say even that doesn't work. Is there anything else? Or is this the end of the line? No, we're not quite at the end yet.
¶ Long-Term Strategies: Assistance and Formulary
Because some drug manufacturers also just offer straight-up discounts, like financial assistance. They call it patient assistance programs. So these are need-based programs. The pharmaceutical companies offer some of them. Other times they're offered through nonprofit organizations and they can make your medicine available for free or at a big discount. So unlike a coupon, you can't just like pull it up on your phone. You have to actually fill out an application.
Some applications are much more rigorous than others, and they all have requirements. They may be like, if you have insurance, we can't help you, or your income is too high, we can't help you. This is absolutely like you have to kind of see if there's something there for you. And they may require your doctor to send in paperwork.
And you can search for them individually online. If you search for the name of your drug and patient assistance program, you'll probably get some answers. But if you're looking for multiple drugs or just want a big resource, there's a site called Needy Meds. So I'm wondering, a lot of folks are choosing their health insurance plans right now. What should people who take prescription drugs be thinking about as they look over plans? Yeah, the last tip is actually...
in some ways, the place to start if you can start early enough. A lot of us don't have a lot of choices when we pick insurance, but we can at least get information about any choices that we do have. There's this super important document that I never... heard tell of until I'd been reporting on healthcare for a minute. It's called the formulary. And the formulary is your insurance plan's list of all the drugs. All the drugs. And
how much you will pay for any given drug. So during open enrollment is when you've got to find that formulary for any plan you're looking at. So if you're shopping on healthcare.gov or your state's Affordable Care Act marketplace site. You can find it there online. I mean, you might have to hunt around a little bit. If you're getting this from HR, you ask, like, I need to see the formulary for next year's insurance plans. And then you...
If you're lucky, you know, you get it in electronic form and you hit control F, right, find for the drugs that you need to take. And that's where it tells you this is what your medicines are going to cost you next year under this plan. This is also the time when if you're like, no plan that's being offered to me has my meds at the prices that are right for me. Now you have a head start.
Right. It's the fall. The year hasn't started yet. And this is when you go to your provider and you're like, hey, what are alternatives? They say this drug for my condition isn't covered, but this other one is. Can I take that one? And if your doctor's like, no, you're like, great, let's start that process now of hitting the appeals, hitting the prior authorizations so that when it's January 1st, we've sorted it out. Yeah, that's a good point. That's a good tip.
Yeah, it's I mean, it's like the super pro tip. And, you know, the sad part is that it's a thing you have to do every year. Right. Like you solved it for this year, your insurance, your setup, you're on a plan that covers what you need or you fought the battle to get it covered. And then next year, you know, your work is like, yeah, we changed insurance plans.
Like, OK, what's the formulary this time? And I got to start fighting again. Or if you're on Medicare and the drug benefit there, it's called Part D. Those plans are all administered by private insurance companies. And a lot of them change every year.
change the formulary. So Jeannie, who we talked to at the beginning, she's working with seniors who every year, she's like, let's look at that formulary. And if they didn't do that with her, they'll come to her in January and they'll be like, I don't know why my medicine is $300 now. It's exhausting. I need a nap after thinking about all this. You and me both, man. Dan Weissman, thank you so much. Mariel, thanks so much for having me. That was Dan Weissman.
¶ Episode Recap and Final Tips
Host of the show, An Arm and a Leg, a podcast about why healthcare costs so freaking much and what we can maybe do about it. All right, time for a recap. Takeaway one. If you're picking up a prescription and it costs more than you expected, first find out if there's been a mistake. Like maybe the pharmacy doesn't have your insurance information or input it wrong. Takeaway two, ask your pharmacist for coupons or discounts and also look for them online.
Takeaway three, ask if there are any alternative drugs that you could take. And if not, see if they'll write a letter of medical necessity to your insurance company to get them to cover this drug. Takeaway four, that process can take a while. So in the meantime, find out if your doctor's office has any free samples of the drug that can tide you over.
Takeaway five, look into financial assistance programs. Some drug manufacturers offer these based on financial need, and nonprofit groups sometimes offer these too. One site that can help you navigate your options is called Needy Meds. And takeaway six, before you choose your health insurance plan for next year, ask to see the formulary for each plan you're considering. That'll show you all the drugs your insurance covers and how much you'll pay for each one.
This could help you make decisions about a plan or help you get a letter of medical necessity from your doctor before the new plan year starts. Okay, before we go, I have a favor to ask. If you have a second, would you leave LifeKit a five-star review? If Life Kit has ever helped you save a little money, make a healthier choice for yourself, or made you feel more seen, a five-star review is a great way to show your support. And thank you.
This episode of Life Kit was produced by Claire Marie Schneider. Our visuals editor is Beck Harlan, and our digital editor is Malika Garib. Megan Cain is our senior supervising editor, and Beth Donovan is our executive producer. Our production team also includes Andy Tegel, Margaret Serino, and Sylvie Douglas. Engineering support comes from Becky Brown with fact-checking by Tyler Jones. Special thanks to Emily Pizzacretta. I'm Mariel Segarra. Thanks for listening.