By Carla MillsCarla Mills is a licensed and accredited Nurse Practitioner who has been a practicing clinician for more than 20 years. She is the author of A Nurse Practitioner’s Guide to Smart Health Choices, an easy to understand, medical reference guide for patients with no prior medical knowledge. Read her blog at maverickhealth.com.
Times are hard and people are struggling. I have written many times about the importance of medications. They are life saving, but they must be taken faithfully and exactly as prescribed if they are to do any good.
But what if you can’t afford your medications? You do have options, and almost every drug company has programs that can help. First let’s first look at who is in control of your medication coverage (hint—it’s not your prescriber).
Health Care Then and Now
Maybe you remember simpler times in medicine, when your doctor was in charge of everything, and you didn’t have to think about your health or health care. Marcus Welby, MD, was on TV, but even back then he was just as fictional as all the other TV characters.
Those days of Marcus Welby fantasies are gone and they won’t be coming back. According to data from the American Medical Association, only 32% of physicians were practicing in primary care in 2007—the rest were specialists. Those physicians who still do practice primary care are harried, overworked, and underpaid. An average physician visit today lasts about 7 minutes—15 minutes is a long visit. This is not because the doctor doesn’t want to spend more time with you; it’s because reimbursement for primary care has shrunk so low that he/she can’t afford to spend more time with you.
In many physicians’ offices and in independent practices in a few parts of the country, you may choose to see an NP instead of a physician for your care. When you see an NP, your appointment usually lasts longer—15 to 30 minutes. That’s because NP practice is a little different than physician practice. While NPs perform the same clinical tasks doctors do, NPs practice with a different philosophy. They see themselves as partners in your care. NPs want to get you well and teach you how to keep yourself well. The fact is that in the healthcare system as it exists today, if you aren’t an active partner in your own care, you are in peril.
The Current Medication Debacle
Your prescriber, whether that is a physician, a physician assistant, or an NP, is NOT the one in charge of what medications you will get—your insurance company is. It’s not the way it should be, but it’s the way it is.
This is how it works. Every individual policyholder (assuming you are lucky enough to have health insurance) is allowed medications from a drug list called a “formulary.” A formulary lists drugs—both lower- and higher-cost medications— that a particular policy or plan covers. In order for you to be prescribed higher-cost brand-name drugs, insurance companies often require that you first “fail” a lower-cost generic form of the drug. They require documentation in your medical record that you were already prescribed the lower-cost drug and it didn’t work. Some insurance companies won’t pay for certain high-priced drugs at all. If you want those drugs, you have to pay for them yourself out of pocket.
Your prescriber does not know your particular formulary or drug preferences. Just as your prescriber doesn’t know what you like to watch on TV or what color car you would choose to buy, he/she also doesn’t know whether you want to pay extra for brand-name drugs or stick only with generics to save money. Your insurance company only wants to cover generic drugs, but not all drugs come in a generic form. It is up to you to provide your particular drug formulary to your prescriber and communicate your drug preferences.
One of the most burdensome tasks that has fallen to primary-care providers—and one that is getting worse with each passing day—is the requirement for “preauthorization” of brand-name medications. This is what happens… Your prescriber starts you on a medication, maybe giving you samples to see if the drug works before you purchase it. You try the samples and do well on the drug. It achieves its desired effect, and you have no side effects, so a prescription is written that you submit to your insurance company. If it is not a generic medication—and it won’t be because generic medications are not sampled to medical offices—the insurance company may require you to first “fail” a generic form of the drug if there is one; sometimes, if there isn’t a generic form of the drug, they want you to be put on a different drug altogether. If they don’t require that you fail another drug first (called “step-therapy”), they often require a medication be “preauthorized.”
“Preauthorization” makes your prescriber fill out a lot of paperwork and waste a lot of time “defending” his/her decision to choose a particular drug for you. So you see, your prescriber is NOT in charge of what drugs you are allowed to have—your insurance company is. If the preferred drug is finally approved, you will still have to pay more for it. Some prescribers refuse to do drug preauthorizations. Many medical practices simply can’t afford the lost staff time and extra labor. While all that work by the prescriber may save you and your insurance company money, it is putting primary-care providers out of business!
What You Can Do
It is essential that you be an active partner with your prescriber to find a medication regimen that is acceptable, affordable, and effective. Your prescriber needs to know which meds you are willing to pay more for in order to get a brand-name drug and when you need to be prescribed generics. If you have been provided a drug formulary, it is very important that you give it to your prescriber. Remember, your prescriber does not know your particular formulary or drug preferences.
Unfortunately, you can no longer just leave prescribing up to the prescriber. You have to become an active participant in your care and you—not your prescriber—must communicate directly with your insurance company to learn about your medication coverage options. It’s not reasonable to expect your prescriber to do your shopping for you.
Back to the Question of What to Do If You Can’t Afford Your Meds
Every pharmaceutical company has patient-assistance programs to help people who can’t afford their brand-name drugs. There will be no patient assistance for generic drugs through the pharmaceutical industry, but there may be deals you can find in the marketplace. Each person’s circumstances and coverage will be different, so it pays to learn about your own and shop around.
Big box stores like Walmart and others are now offering $12 deals for 3-month supplies or $4 for one month’s supplies on certain “formularies” of generic drugs. Some grocery and other in-store pharmacies even offer a few drugs free. Some people are choosing to bypass their insurance companies altogether and just pay cash for their meds. If you are on medications that have no generic equivalents, patient assistance through a pharmaceutical company may be the way to go.
Four Tips when Seeking Assistance
1. Maintain a close partnership with your prescriber to make sure you are being prescribed drugs that are both the most effective and most cost effective.
2. Plan to do all your own legwork. You are shopping for yourself. Complete any needed forms yourself and then bring them to your prescriber if signatures are required.
3. Remember that you are going to all this trouble because these medications are keeping you well and preventing future disease. IF you take them faithfully and EXACTLY as prescribed they will have the best chance of working.
4. If you have conditions that require medications, making the effort and putting up with the hassle of finding affordable and effective drugs is worth it. Medications, when properly prescribed and taken as ordered, are one of the best ways you can save your own life.
Since most people have access to a computer, you may wish to explore some useful patient-assistance programs that are available online. Try accessing the Partnership for Prescription Assistance (www.pparx.org), RxAssist (www. rxassist.org), or NeedyMeds (www.needymeds.org). If these are not helpful, search Google for the name of the specific drug company you need assistance from and call them directly. They can put you in touch with their own patient assistance department. Good luck. And, please, take your medications faithfully—your life depends on it!