By Lindsey Thacker, Certified Pharmacy Technician, YPC Committee Member
I was unprepared that the reality of having chronic health conditions would leave me in a state of financial insecurity. Over the past few years, I have learned to not only advocate for myself, but also for my patients. I wanted to share with you some of the most common questions we get from patients at the pharmacy that are struggling to afford their medication and what can be done to lower the cost.
What happens when the insurance company rejects the claim for a medication?
Prior Authorization: This is a term that nearly all of us have heard, however, many patients do not understand what it means or what the process is. If a medication requires a prior authorization, it could mean several things:
1. The medication is not covered on your insurance plan.
2. The medication is covered on your plan, but you must meet certain requirements for them to pay. When this happens, your doctor needs to submit information to insurance to prove that the medication is medically necessary.
3. The medication is covered on your plan, but it requires step therapy. This means that the insurance would rather pay for cheaper alternatives. If you have tried alternative medications and they were not a good fit for you, your doctor can submit this information to insurance to get the medication covered.
The next big question is what needs to be done. When the rejection pops up at the pharmacy, the pharmacy will contact your doctor’s office and inform them that a prior authorization needs to be completed. Your doctor’s office will then contact your insurance and provide them with the information they need. Then, it is up to the insurance company to decide if they are going to cover the medication. Sometimes it will be an immediate response; however, it could take several days for them to make a decision. From the patient side, there is not much you can do during this process.
If the prior authorization is denied, there is still hope. Your doctor can appeal the prior authorization. If the appeal is denied, they can file a second level appeal. Finally, if that is denied, most insurance companies will let you do an external appeal through a third party.
What if a brand name medication is not covered?
Patient Assistance Programs: The manufacturers want you on their brand name medications. They often have programs to help you get their medication. For example, if you are financially struggling or meet certain requirements, then you may be eligible for this. To see if you qualify, reach out to the manufacturer, and explain your situation. You never know how they might be able to help you until you reach out.
Independent Pharmacy Programs: Some independent pharmacies are partnered with the manufacturers of brand name medication. They will sell the medication for an extremely discounted “cash price”. This information should be listed on the medication’s website.
If a brand name medication is covered, how can I make it affordable?
Manufacturer Savings: If you take brand name medication and have commercial insurance, these are your best friends. Nearly all brand name medications have a coupon from the manufacturer. There are two ways to get manufacturer coupons: looking online and your doctor’s office. If you go online, search the “name of the drug savings” and click on the medication’s website. It will have you fill out a quick form and then you email or download the card. Take this information to the pharmacy so they can apply the savings!
What if a generic medication is not covered?
Prescription Savings Cards: If it is not a name brand medication, prescription savings cards and programs that can help you. There are websites like GoodRx and AmericasPharmacy where you can search the name of your medication and it will show you the price of the medication with their coupon card at different pharmacies. Not all pharmacies accept these, so reach out to your pharmacy before you decide to go this route.
Pharmacy Savings Programs: Walmart, wholesale clubs and many retail pharmacies offer RX savings programs. Walmart has a list of medications that are $4 for a 30-day supply and $10 for a 90-day supply. Wholesale stores will offer a discount for those that pay for a membership to the club. Many retail pharmacies are starting to offer similar programs. If you pay a yearly fee, you can receive a discount on your prescriptions.
What if I cannot afford my medication?
Assistance Programs Run by the State: If you are having a hard time affording your medication, some states offer Medicaid programs that you can use as a supplement. Requirements differ in every state.
Assistance Programs Run by Nonprofit Groups: These programs will help pay for your prescriptions. There are several ways to find non-profit assistance programs. If you are religious, with your place of worship. Many will have assistance programs set up for their members and sometimes even can help people outside of the church. While I am unaware of a program for those with Trigeminal Neuralgia, there are some conditions that have assistance programs to help with copays. If you have other conditions, it could be worth looking into. There are also programs online for those with low income or on disability. If you need help, reach out to several programs, and see what you qualify for. They are here to help you.
RX Savings Cards and Programs: Even if the medication is covered by your insurance, sometimes you can get it cheaper by utilizing these cards and programs as mentioned above.