4 Ways to Get Insurance to Cover Your Prescription Drugs

Reprinted from Consumer Reports / Ginger Skinner / February 12, 2016

If your medication costs have shot up, ask your doctor for help

If your medication prices seem higher than last year, one culprit might be changes to your insurance company’s “formulary”—the list of drugs covered by your health plan.

During the year, insurance plans may change which prescription treatments they cover, and that’s true especially when it’s time to re-enroll.

Formularies are often developed to encourage people to use the least expensive medications whenever possible. But that list can change if an insurer negotiates a better deal with a drug company, if new research shows the medication isn’t as safe or effective as thought, or a less expensive generic version of the drug hits the market.

Even if your drug is covered on an insurance company’s formulary, the full cost of it may not be. Where an insurance company places a drug on its formulary, the list of drugs is further divided into what is called a ”tier”—and it’s essentially a way to determine how much you’ll pay out of pocket for it, through your co-pay. The higher the tier the higher your share of the costs.

"Consumers need to be on guard because drugs can be taken off a formulary at any time, or moved to a higher tier, which could make a big difference in your share of the costs," says Betsy Imholz, Consumers Union's director of special projects.

Most plans have about four levels, or tiers, of coverage, but in the last few years, more insurers have added a fifth tier by splitting the "generics" tier into two: "preferred" and "nonpreferred." Insurance companies do this to encourage people to choose less expensive medications.

Your copay for a drug in the non-preferred generic tier, for example, may be $15, compared to a preferred generic in the lowest tier, where your copay could be $5 or less. 

Diligently checking your plan's formulary (you can find it on your insurer’s website) can help you avoid getting stuck with paying the full costs of your prescriptions. But if it turns out a drug you're taking is dropped or moved to a higher tier, you have several options:

1. Switch Drugs. Ask your doctor to prescribe a drug on your formulary that may be just as effective and safe for your condition. Most plans will offer one or more alternatives to a medication they no longer cover.

2. Ask for an Exception. "Many people don't realize that just because a drug is not on your plan's formulary does not mean it's unavailable for coverage," says Imholz, "Work with your doctor."

If a drug alternative is not possible, your doctor can file an exception, or "prior authorization," through your health plan, requesting that the drug be covered because it’s medically necessary. If that happens, your plan should approve or deny your request within a few days.

3. Try Step Therapy. Depending on what medication it is, after your doctor files an exception, some plans may require that you agree to “step therapy” first, which is a type of prior authorization. It means trying other lower-cost medications that are appropriate for your condition first. If the lower-cost drug doesn’t work for you, your doctor can ask your insurer to cover the more expensive drug. 

4. File an Appeal. If your insurer still denies your request to cover a drug you need, you can file an appeal. You and your doctor can either complete and file an appeals form provided by your insurer, or write a letter that includes the name of the drug, why you need it covered, and any other supporting documents from your doctor. Your insurer's website will provide more details on the appeals process.

If your plan denies your appeal, you can file for an external, or independent, review with your state’s insurance regulator, which will make the final decision.

If your state doesn’t have an external review mechanism, the Department of Health and Human Services (HHS) or an independent review organization will oversee the process. A decision can take up to 60 days and is free if handled by the HHS, but may cost you to $25 if it’s handled by your state or an independent review organization.


When All Else Fails, Shop Around
Filing an appeal can be a lengthy process, and there’s still no guarantee that your insurer will agree to cover your medication. If you end up having to pay more for your medications out-of-pocket, shop around.

Our secret shoppers have found that prescription prices can vary widely from one pharmacy to the next, even in the same zip code. Costco often offers low prices (you don’t have to be a member) and independent pharmacies may be able to negotiate. And ask your pharmacist if you can save more by not using your insurance; many chains and big-box stores, such as Target, Walgreens, and Walmart, offer hundreds of generics for as low as $4 for a 30-day supply and $10 for a 90-day supply.

When it's time to re-enroll or change insurance plans, before choosing coverage, Imholz recommends checking the formulary to make sure the drugs you need are covered and under which tier.


Editor's Note: These materials were made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

A Surprising Way Big Pharma Keeps Drug Prices High

Delaying the release of generics drugs can cost consumers millions, and should be illegal, say consumer groups and the FTC

By Steve Mitchell
Last updated: October 13, 2015

Ten years ago, consumers were on the verge of getting a lower-priced, generic version of the brand nameantibiotic Doryx (doxycycline). But the drug's manufacturer, Warner Chilcott, stopped making the drug in its original capsule form and instead began producing it as a tablet. This seemingly minor change meant that generic manufacturer, Mylan, was blocked from being able to market the matching generic tablet it had been developing.

Warner Chilcott is now embroiled in a lawsuit that charges it used those and similar tactics—such as adding score lines to the tablets and ceasing production of the unscored tablets—to manipulate the patent and generic laws to stay one step ahead of generic manufacturers.

That tactic, called “product hopping,” is a strategy drug makers have begun using in recent years to stall the development of generic versions of a medication so they can keep brand-name drug prices high. But it is coming under fire from the Federal Trade Commission and several consumer groups, which charge in a federal court case that it’s a violation of antitrust law that bilks consumers of millions of dollars in high drug prices.

In the case, the generic-drug company Mylan accuses Warner Chilcott of using product hopping to prolong its patent on Doryx. A district court in Pennsylvania sided with Warner in April, ruling that its product hopping tactics did not violate antitrust law.

But Mylan has appealed the decision. And last week it got a boost from several consumer groups, includingConsumers Union, the policy and advocacy arm of Consumer Reports, AARP, Consumer Action, Consumer Federation of America, Families USA, U.S. PIRG, and others, which jointly filed an amicus brief in support of the appeal.

The FTC also flexed its muscles, filing a separate amicus brief in support. The consumer groups and the FTC fear that if the initial decision is left to stand, it will open the door for other drug companies to use product hopping to stifle generic competition and keep drug prices high. And that would mean consumers would be stuck with a hefty bill.

The delay of getting even one generic drug on the market could easily cost consumers hundreds of millions of dollars, says George Slover, a senior policy counsel for Consumers Union. “If product hopping is allowed to become standard practice, the cost to consumers could be staggering."

Slover says there’s hope the courts will declare product hopping illegal. In May, a different federal appeals court, the Second Circuit, upheld a ruling that Actavis’ product hopping with its Alzheimer’s medication Namenda was illegal. In that case, New York state accused Actavis (now Allergan) of switching Namenda from an immediate-release to an extended-release formulation to delay generic immediate-release alternatives from being launched.

When we contacted Allergan, which now owns both Doryx and Namenda, for this story, it declined to comment on either case.

It could take a prolonged battle in the courts to finally settle the law against product hopping. But Slover notes that it took more than a decade for consumer advocates to stop another generic-blocking scheme called “pay for delay.”

Under that tactic, the brand-name drug maker pays off a generic manufacturer to delay the launch of its generic formulation of the drug, so the brand name can continue to sell at a high price. For years, courts ruled that drug companies were shielded from the antitrust laws because of their patent. The FTC ultimately took the fight against pay for delay to the Supreme Court, which ruled in 2013 that the antitrust laws apply to the scheme.


Editor's Note: These materials were made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

Garage Sale

Well, the dreaded community garage sale is over. The rain helped shorten the weekend's plan, although there were a few folks who were out in the rain selling their stuff on Sunday.

I stayed true to my word--"nothing comes back in the house"! Next time I will say--"nothing comes back in the house and/or garage"!

It really wasn't as bad as I thought it would be. We did get rid of some items we didn't need or want anymore and in doing so, we didn't have to contribute to the landfill.

Bonus: I took the opportunity to distribute Consumer Reports' Best Drugs for Less brochure, which educates people about generic drugs and other useful information.

Prescription Drug Savings

Shopping Around Brings Steep Prescription Drug Savings, Report Finds


THURSDAY, March 28 (HealthDay News) — Prescription drug prices at U.S. pharmacies can vary widely, and failing to shop around could result in people overpaying by as much as $100 or more a month on average, depending on the drug, a new study finds.

Researchers at Consumer Reports called more than 200 pharmacies across the United States to get retail prices (out-of-pocket costs) for a one-month supply of five popular medicines that have recently gone generic.

The medicines were: the diabetes drug Actos (pioglitazone); the antidepressant Lexapro (escitalopram); the cholesterol-lowering drug Lipitor (atorvastatin); the blood thinner Plavix (clopidogrel); and the asthma drug Singulair (montelukast).

For a one-month supply of these drugs, there was a $749 difference between the highest- and lowest-priced stores — a more than four-fold difference, according to the study in the May issue of Consumer Reports magazine.

Overall, Costco outlets had the lowest retail prices and CVS had the highest, the report found. Among the specific findings:

A month’s supply of generic Lipitor cost $17 at Costco, compared with $150 at CVS. Prices at Rite Aid and Target were also high.

A month’s supply of generic Lexapro cost $7 at Costco and $126 at CVS. On average, Rite Aid, Walgreens and grocery store pharmacies also charged higher prices.

A month’s supply of generic Plavix cost $12 at HealthWarehouse.com and $15 at Costco, compared with $180 at CVS.

Different business approaches are one reason for the wide price variations, according to Lisa Gill, prescription drugs editor at Consumer Reports.

“It really comes down to a store’s business model. For example, big box stores tend to use their pharmacies as a way to get consumers through the door with the expectation that they’ll buy other things,” she explained in a Consumer Reports news release.

If you want to get the best deals, shop around and always request the lowest price, Gill advised.

“A consumer can’t assume that the price of their prescription medications is set in stone,” she said. “One of the big takeaways is that you have to ask for the best price and see if your pharmacist will work with you. Especially for the independent pharmacies, if they want to retain your business and loyalty, they will help you get the best price,” she said.

Other ways to save money include:

Using generic drugs, which contain the same active ingredients as brand name drugs.

Getting refills for 90 days, not 30 days. Most pharmacies offer price reductions on a three-month supply of a medicine.

Look for other discounts. All chain and big-box pharmacies offer discount generic drug programs, with some selling hundreds of generic drugs for $4 a month or $10 for a three-month supply.

Try shopping in rural areas. The study found that some grocery store pharmacies and independent drug stores had higher prices in cities than in rural locations. For example, a 30-day supply of generic Actos cost $203 at a pharmacy in Raleigh, N.C., compared with $37 at a pharmacy in a rural area of the state.