“I don’t need to worry about drug prices; I have insurance!”
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 co-pays 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, and the payors (whether the insurance company, your employer, or even the government) need to control their costs. 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 (HDHP’s), which means they’re on the hook for most of their healthcare costs throughout the year.
- Formularies. Formularies are the list of drugs that your insurance will 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’ll pay significantly more.
- Tiers. Formularies often price drugs by tier—each tier indicates how much you’ll pay. Recently, more and more tiers have been added to increase your co-pay. 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 6 tiers.
- Co-insurance vs. Co-pay. Sound confusing? It’s not. A co-pay is a set amount, regardless of the cost of the drug. Co-insurance means you’re responsible for a percentage of the total cost. 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 it’s covered. Many drugs these days require the insurance company’s approval before you fill—and there’s no guarantee they will approve it.
- Step Therapy: Some drugs (typically expensive ones) require you to try another (typically cheaper) drug first and provide evidence that the first drug hasn’t worked before they’ll approve the second.
- Quantity Limits: Most insurance formularies will limit the amount of a drug you can purchase at one time.
Wait—here’s the good news! Cash and coupon prices are often lower than insurance co-pays, and GoodRx offers 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 6 tips will help you get the most out of GoodRx if you have insurance.
- Know what you should be paying for your prescription.GoodRx lists free discount coupon prices, and provides the coupons so you can receive a discounted price when you pick up your prescription. The coupons are free and there are no obligations or hidden fees. You can also compare with cash prices, pharmacy membership program rates, and online pharmacies.
- You can still use a discount if you have health insurance.You can always use a GoodRx discount instead of your prescription insurance if the cost is lower. Our coupons can’t be used to lower your co-pay, but you can ask your pharmacist to use a coupon, pharmacy membership program, or check the cash price instead.If you don’t already know your co-pay 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.
- Using a discount at your pharmacy is easy. If you choose to use a GoodRx coupon or other discount program, just ask the pharmacist not to run your prescription through your insurance (they do this all the time). Ask that they use the coupon or discount card to process the transaction instead. If your pharmacist has any trouble using the discount, ask them to call the phone number on the coupon for help processing or to answer any questions they might have.
- How does GoodRx help?Health insurance will offer either a discounted co-insurance price on your prescriptions, or a set co-pay (often starting at $10).When you’re deciding whether to fill with your insurance, keep these questions in mind:
- Is this drug covered by your plan? If so, how much will it cost? Remember, your formulary lists the drugs your plan will cover. Your co-pay may be determined by tiers—or for many brand name drugs, your plan may cover just a percentage of a negotiated price. Check your insurance company’s website to see if they provide pricing. Some drugs may cost you more with insurance than if you use a GoodRx coupon and pay cash.
- Have you satisfied your deductibles? If you haven’t, you’ll usually still get a discounted rate negotiated by your insurance plan—but it may not be as low as the prices GoodRx can find. Check your insurance company’s website to find your deductible status.
- Can GoodRx beat your co-pay? Don’t be surprised if there are local and mail order prices lower than your co-pay. The typical insurance plan in America offers a $10 co-pay for preferred drugs (and it goes up from there). Many, 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 co-pay may be $10 for a 30-day supply. What you may not know: many pharmacies have metformin available for $5 or under with a discount, and some, like Publix or Meijer, will even fill your prescription for free. Compare prices at pharmacies in your area here.
- You can also use a discount if you have Medicare.Just like with other types of insurance, you can still use GoodRx if you have Medicare Part D or Advantage. Your Medicare co-pay may not be the pharmacy’s lowest price, especially if you haven’t reached your deductible, are in the donut hole, or are purchasing a drug that’s not on your formulary. GoodRx can still help you control your prescription drug costs and find prices that are lower than your typical co-pay.Even better, GoodRx can tell you your Medicare co-pay, 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, and let you compare your co-pay with our prices on the same page.
Just add your Medicare plan after searching for any prescription on GoodRx to compare our prices with your co-pay.
- Need more than a coupon? GoodRx offers other ways to save.GoodRx also provides savings tips, suggestions for alternative less-expensive drugs, information on manufacturer coupons, assistance programs, drug shortage and recall info, pill identification tools, and much more. Our goal is to make you an informed consumer by providing as much information as possible in an organized, easy-to-read way.