At GoodRx, we hear people say this all the time. After all, isn’t that what health insurance is for? You pay your premium and then insurance pays for your medical bills. Right?
If you use GoodRx, you probably already know that prescription drug insurance isn’t what it used to be. Not long ago, most Americans had generous prescription benefits as part of their insurance. You probably remember $10 copays and never being shocked at the pharmacy counter.
So, what’s changed? In general, health insurance is simply paying for less than it used to. The cost of healthcare has gone up, payors (whether the insurance company, your employer, or even the government) need to control their costs and they shuffle that cost to you, the patient, in different ways. As a consumer, you need to watch out for these “features” of your insurance policy, all of which could cost you at the pharmacy counter:
- Deductibles. Most plans these days have deductibles, where you’re responsible for your own costs up to a certain limit. In fact, deductibles are increasing faster than wages in the US. Some common plans now have up to a $5,000 deductible! Many Americans now have high-deductible health plans (HDHPs), which means we’re on the hook for most of our healthcare costs throughout the year.
- Formularies. Formularies are the list of drugs that insurers cover—and they’re shrinking. Fewer drugs are being covered and more drugs are being excluded. If your drug is not on the list, you might be hit with the full cash price of the drug unless you find other ways to save.
- Tiers. Formularies often price drugs by tier; each tier indicates how much you’ll pay for a covered drug. Recently, more and more tiers have been added to increase your copay. A Tier 1 drug might be a $10 co-pay, a Tier 2 might be $30, etc. There are now some plans that have up to six tiers.
- Copay vs. co-insurance. Sound confusing? It’s not. A copay is a set amount your insurance requires you to pay for a drug, regardless of its retail price. Co-insurance means you’re responsible for a percentage of the drug’s full price. More and more, plans are moving to co-insurance, which could mean significant increases for you.
- Prior authorization. Just because a drug is on formulary doesn’t mean your prescription is covered. Even when a drug is on formulary, some insurers require patients to also get approval for the drug before they’re allowed to fill their prescription. It often means getting a doctor to send in a prior authorization form—and there’s no guarantee they will approve it.
- Step therapy. To contain costs, insurers prefer that you use cheaper drugs before trying more expensive ones—and they often insist on it with step therapy. If a drug you prefer requires step therapy, you have to try another (typically cheaper) drug first and provide evidence that it didn’t work before your insurer will approve your preferred (typically more expensive) drug.
- Quantity limits: To ensure patient safety and keep costs low, most insurers will limit the amount of certain drugs you can purchase in a given time period. Quantity limits may be day-to-day, week-to-week or month-to-month and will differ between drugs. Drugs typically under quantity limit restrictions are those that are intended for short-term use, have serious side effects when overused or have high potential for abuse.
Wait—here’s the good news! Cash and coupon prices are often lower than insurance copays, and GoodRx is an easy way to make sure you’re getting the lowest price out there, whether you have insurance or you’re paying out of pocket. These tips will help you beat your insurance copay.
1) Get to know your insurance prices.
Health insurance will offer either a discounted co-insurance price on your prescriptions, or a set copay (often starting at $10).When you’re deciding whether to fill with your insurance, find out 1) whether the drug is covered by your plan and 2) how much it will cost.
Remember, your formulary lists the drugs your plan will cover and tiers will ultimately determine your copay or co-insurance. If you don’t already know your copay or co-insurance for your prescription, you can often use your insurance’s web portal to look up what you will pay—or you can give them a call to get an estimate.
Even better, if you have Medicare Part D, you can find your copay, as well as the prices you’ll pay until you meet your deductible, while you’re in the donut hole, and after you leave the donut hole all on GoodRx.com. Just add your Medicare plan after searching for a drug on GoodRx.com to see prices.
2) Research discount prices.
Some drugs may cost you more with insurance than if you use a coupon and pay cash. The typical insurance plan in America offers a $10 copay for preferred drugs (and it goes up from there). Many generic drugs can be bought for less than $10. Why pay $10 when you could pay $4?
For example, if you take metformin for diabetes, your copay may be $10 for a 30-day supply. What you may not know is that many pharmacies price metformin at $5 or less with a discount. And some, like Publix or Meijer, will even fill your prescription for free.
On GoodRx.com, you can compare cash prices, discount prices, pharmacy membership program rates, and prices at online and local pharmacies. GoodRx coupons are free and there are no obligations or hidden fees.
3) Yes, you can use a discount even if you have insurance.
Prescription discounts, including those from GoodRx, can be a great option if you don’t have health insurance, but if you do have insurance, you can always use a GoodRx discount instead of insurance if the cost is lower. Our coupons can’t be used to lower a copay, but you can ask your pharmacist to apply a coupon, use a pharmacy membership program or check the cash price instead.
What if I have Medicare Part D?
How do I use a coupon at the pharmacy?
4) Use GoodRx to contribute to your deductible.
If you purchase a medication with a GoodRx coupon and the drug is covered by your insurance, you may be able to submit your receipt to your insurer and count that towards your deductible. That way, you’ll still be able to take advantage of your insurance coverage later.
This applies to almost all types of insurance plans, including those from private insurers, commercial health exchanges, Medicare and Medicaid. You’ll want to contact your individual provider to find out what information they’ll need from you and how to submit it.
5) Need more than a coupon? GoodRx offers other ways to save.
GoodRx also provides information about other ways to save on prescription medications like savings tips to ask your doctor about, suggestions for alternative drugs that might be less expensive, information on manufacturer coupons and patient assistance programs, and much more. Our goal is to help you become an informed consumer by providing important information about drugs and drug savings in an easy-to-understand way.
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