You and your loved one are at a doctor appointment. It is with a specialist that you have waited months to see. The specialist mentions a newer medication that could be just the perfect thing for your loved one’s ongoing ailments. The specialist goes on to discuss all the things it could help with, and better yet, it has little to no side effects. You walk out of the appointment with a renewed sense of hope and feeling like you can breathe a sigh of relief. Your loved one has been suffering for some time, and this seems like it will be the perfect solution. Later that day, you get a call from the pharmacist. They say that the medication is not covered by your loved one’s insurance and that it would cost over $400 a month. Plus, with it being newer, there were no generic options available for this particular medication. You are back to where you started, feeling a bit defeated, as you thought your loved one could really get some benefit from the new medication. However, at that price, it was just not feasible. Does this perhaps sound a little familiar?
According to American Association of Retired People (AARP), between 2016 and 2017, retail prices for over 260 brand name prescription medications widely used by older Americans, including Medicare participants, increased by an average 8.4%. Just in 2017 alone, brand name medication prices increased four times faster than general inflation. The average annual cost for just one brand name medication that is used on a consistent basis for a chronic condition, was almost $6,800 in 2017. In 2015, it would have been closer to a $1,000 less for that same brand name medication. These ongoing trends of rising costs of brand name prescription medications, are beginning to have a profound impact on older adults. There is not only the financial aspect, but also their actual physical health being impacted. Some older adults are having to stop taking necessary medications because they can no longer afford it, which ultimately leads to poorer health and rising healthcare costs. (1)
Even if your loved one is enrolled in Medicare Part D, there can still be considerable out-of-pocket drug costs, especially if they fall into the Medicare coverage gap, also known as the infamous “donut hole.” Do not let this name deceive you. It is not good. When in the coverage gap, it means that you and your drug plan have spent a certain dollar amount for covered medications and now you have to pay 25% of a brand name and 37% of a generic medication. Depending on the costs, this can get fairly expensive. No one wants to get to this point. If your older loved one has a chronic condition that requires a number of ongoing medications, it can be pretty easy to find yourself in this place. However, you are not in the coverage gap phase forever. After a certain dollar amount is spent, then you get out of the coverage gap period and into what is considered the catastrophic coverage phase. A little bit of a dramatic word choice by Medicare, but what that means is you pay significantly lower copays. If your loved one is qualified and receiving extra help from Medicare to pay for medications, they will not fall into this coverage gap. (2) Clear as mud, right? Well, how can you potentially catch a break from the ever increasing costs of prescription medications?
I am sure you have seen those prescription discount cards in various drug stores when at the checkout counter. Do those discount prescription cards truly work? The answer is sometimes. It depends on the situation. I know, not necessarily the answer you want to hear. Generally, the discount card cannot be combined with any other insurance. It would be for when the copay for a prescription is too high or it is not covered at all with your prescription plan. With certain discount cards, you cannot utilize it at all if you have Medicare, even if you would like to pay directly instead of filing a claim. Keep in mind, discounts can vary by area and by pharmacy, but some cards may offer up to an 80% discount on generic medications. Some may require you to enter personal information for access. If you use a discount card, it will not go towards out-of-pocket costs or deductibles with your current plan. (3)
Things to Consider
There are a lot of prescription discount cards to choose from out there. Therefore, the following are some things to consider when trying to decide:
1.) How much does the discount card cost? Is it an annual or monthly fee?
2.) Are there restrictions? Such as: age, income, whether or not you have health insurance such as Medicare and/or secondary insurance, if it would need to be mailed, etc.
3.) Does your pharmacy accept that particular discount card?
4.) Can it be used on the medications you are currently taking? If so, what would be their prices?
5.) Have you compared the cost of the medication with another pharmacy? It always helps to check around. With that being said, some pharmacies cannot necessarily check the cost, without them having the actual physicians order in their system.
There are also some membership organizations that offer discount prescription cards, such as AARP and American Automobile Association (AAA).
If a free prescription discount card does not work for your particular situation, please do some research before deciding to purchase a discount card. Like anything else, there are scams out there! Check the reviews and the Better Business Bureau. Also, be sure that you have answers to all the questions above.
Lastly, if you are unable to find a prescription discount card that will cover your loved one’s pricier medications, especially if it is a brand name, contact the physician’s office. Let them know the situation and ask if there is another medication that is comparable and that may have a generic form. It can still be discouraging, but remember that perhaps that newer, pricier medication would not have even helped your older loved one anyway. Just remain persistent and do not lose hope. It may be a trial and error process until the physician finds just the right medication that works for your loved one and for the budget. Plus, things are always changing and evolving. You never know what may be on the horizon. Then once the time of year comes where you can switch to a different prescription plan through Medicare, check out other plans to see how much the cost would be for your loved one’s medications, including the ones that want to be tried but couldn’t afford with the current prescription plan. It pays to shop around, because the prices can vary greatly. Medicare has a feature on their website where you can compare the prices of medications with the various prescription plans available. However, before you decide on which plan, it is always good to call the particular insurance company associated with the plan to double check on what the price would be with that particular plan. The phone numbers are made available on the Medicare website.
The world of healthcare is complicated and overwhelming to say the least. As the care needs of your older loved one become complex, don’t try figuring it out all on your own. Reach out to Denver Senior Care consultants for support, guidance and resources.