How to Make Prescription Drugs More Affordable — With or Without Insurance
Key takeaways:
Prescription drug insurance is available through commercial or government plans. Choosing a low or no deductible plan that covers your specific medications can help you save on prescription drug costs.
You may be able to lower medication costs through insurance with prior authorizations or step therapy programs. Manufacturer copay cards and free trial offers can also help you save on the cost of your prescriptions.
Patient assistance programs, charitable pharmacies, and discount cards are available to help lower medication costs for those without insurance. Some pharmacies also offer certain medications at a low monthly cost.
Table of contents
Doctors, nurses, and other healthcare providers work hard to make sure you get the care you need. And that includes making sure you can afford your medications. But all too often, people walk away from the pharmacy counter without their medications because their prescriptions are just too expensive.
There are several options that can help make your medication more affordable. Let’s review some ways to save, whether or not you have prescription drug insurance.
What are the main types of prescription plans?
There are two main categories of health insurance plans: government and private (commercial). Private insurance plans can come from an employer or through the Affordable Care Act (ACA).
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GoodRx for HCPs has savings that can beat insurance copays and reduce your need to complete prior authorizations.
Government plans include Medicare, Medicaid, and Tricare. State health insurance plans are also government plans. CalPERS in California is an example of a state health insurance plan.
Each type of plan has options that can help make medication more affordable.
Medicare Part D
Medicare Part D covers prescription drugs and is available to people eligible for Medicare. Medicare Part D coverage has 4 different stages: deductible, initial coverage, coverage gap, and catastrophic coverage.
The deductible is an amount paid out of pocket before prescription coverage starts. After you meet your deductible, you’re in the initial coverage window and will pay a set copay for medications.
Once your total medication cost (the amount your insurance pays plus the amount you pay) reaches a set amount, you’ll enter the coverage gap. In the coverage gap, you’ll pay up to 25% of the cost of your medications. And once your medication cost reaches a second set amount, you’ll enter catastrophic coverage. You’ll pay 5% of the cost of your medication or less at this point.
How to save: There are ways to save on medication costs with Medicare Part D. Some options include:
Choose a low or no deductible plan.
Choose a plan that covers your medications at the lowest copay.
Choose a plan with a low monthly cost.
Choose a plan that provides extra coverage in the coverage gap.
Choose a Medicare Advantage plan that combines medical and prescription drug coverage.
Apply for the Extra Help program, which helps with Medicare Part D costs.
Medicaid
Medicaid is a health insurance plan funded by both state and federal governments. It covers low-income families, pregnant women, and people living with disabilities. The Children’s Health Insurance Program (CHIP) is a medicaid program that’s specifically for children.
Medicaid was greatly expanded during the COVID-19 pandemic. But many states are now rolling back, or unwinding, Medicaid coverage. Up to 24 million people could lose coverage as a result.
How to save: There are ways to save with Medicaid plans and steps you can take if your Medicaid coverage isn’t renewed. Some options are:
Stick to the formulary. Most Medicaid programs have a specific list of prescription medications they cover. So make sure your provider knows what plan you have. This can help them choose a medication that’s covered by your plan.
Find other coverage. You may be able to enroll in an affordable plan through the ACA Health Insurance marketplace. Another option is short-term insurance, which can be helpful if you’re waiting for coverage through an employer or spouse to kick in.
Commercial insurance
There are several types of commercial insurance plans. How much you pay for your medication depends on the deductible and the copay or coinsurance of your plan. It also depends on your plan’s formulary, and where your medications fall within it.
How to save: There are several ways to make prescriptions more affordable with commercial insurance, including:
Choose a no or low deductible plan. This limits how much you’ll spend out of pocket before your coverage kicks in. Be aware that the prescription deductible is often separate from the medical deductible on certain plans.
Choose an insurance that covers your medications at the lowest cost.
Choose a plan with a copay versus coinsurance. Coinsurance typically involves paying a percentage of the medication’s cost. A set copay amount is often more affordable than coinsurance.
Stick to the formulary. As mentioned, medications on your insurance formulary are more likely to be covered at a lower cost. Your provider can help make sure they’re prescribing medications that are included in your plan’s formulary.
Use manufacturer copay cards. Drug manufacturers may offer a copay card to lower the cost of a brand-name medication. They usually only work if you combine them with a commercial insurance plan.
What can you do if a prescription isn’t covered by your insurance plan?
Prescription insurance plans use a number of tools to control costs. If your medication isn't covered from the start, there may be steps you can take to change that. Here are some common ways you may be able to get your medication covered.
Prior authorizations
A prior authorization (PA) is a common insurance rejection. It’s a way insurance companies control costs and make sure you’re following proper treatment guidelines.
If a medication requires a PA, your provider needs to let the insurance company know why you need it. Sometimes, they just need to provide your diagnosis. Other times, they’ll need to let the insurance company know what other medications you’ve already tried.
Often, your pharmacy will work with your provider’s office to get a PA approved. But you can work with your insurance company and provider to move the process along, too.
Step therapy
Some insurance plans may require step therapy. This means you’ll need to try other medications in a certain order before they’ll pay for the one prescribed.
Sometimes, your provider can override this if the other treatments aren’t an option for you. Otherwise, you may need to follow the treatment steps required by the insurance.
Tier exceptions
Tier exceptions allow you or your healthcare provider to ask your insurance company to cover your prescribed medication at a lower cost. The insurance company may need proof that other medications don’t work or aren’t an option for you.
Insurance appeals
Sometimes, even after all of these steps, an insurance company still won’t cover your medication. In that case, your last option may be an insurance appeal. The exact process differs from plan to plan, but you’ll often have forms to fill out and medical records to submit. If your state has a consumer assistance program, they can also help with the appeals process if you need it.
Do mail-order pharmacies help you save money?
Sometimes. Some insurance companies require you to use a mail-order pharmacy. Others may charge a lower copay or coinsurance for medications if you get them from a mail-order pharmacy. So they may be able to save you money on your prescriptions.
This information should be available on your insurance plan’s website, or by calling customer service. In some cases, you may be able to override a mail-order requirement by speaking with your insurance representative plan. But this varies from plan to plan.
Specialty and limited distribution medications
Some medications are only available through a mail-order pharmacy. Specialty or limited distribution medications are a common example. These are medications for rare conditions, and they can be very expensive. So they’re often only available from a specialty pharmacy. The pharmacists and staff at a specialty pharmacy are highly trained on these medications. They are also experts at handling insurance coverage issues for them. Many specialty pharmacies are also mail-order pharmacies.
If you need a specialty medication, your provider will help you find a specialty pharmacy that can ship your medication to you. They’ll also work with you to make sure you’re getting the medication at the lowest cost.
What if you don’t have prescription drug insurance?
If you don’t have insurance, there are several options available to help you save on the cost of your medications.
Patient assistance programs
Patient assistance programs are offered by drug manufacturers as well as certain nonprofit and government agencies. Program requirements vary, but they’re typically meant for people who are uninsured or underinsured.
Free trial cards
Free trial cards are another way to get your medication at no cost. You can get a free trial card from your provider. They’re sometimes available on the drug manufacturer website, too.
Your healthcare provider may also have free samples of certain medications they can give you in the office.
Charitable pharmacies
Charitable pharmacies provide medications at low or no cost to people who meet their requirements. Dispensary of Hope is a nonprofit company that can help connect you with a charitable pharmacy in your area. The Charitable Pharmacies of America website is also a good resource.
The requirements for charitable pharmacies differ by location. It’s best to check with them to make sure you qualify before sending them your prescription.
Reduced-price lists and coupons
Many pharmacies, both chain and independent, offer reduced-price drug lists. The lists usually consist of generic drugs at about $4 per month. Ask your local pharmacy if they have a program in place for lower-cost medications.
Free resources, such as a GoodRx Savings Card or digital coupon, can help you get your medication at a lower price, whether or not you have insurance. Many, but not all, pharmacies accept discount cards for prescription savings.
For providers: GoodRx also has a provider mode experience, which offers a cost comparison tool and information about brand-name drug savings programs. Providers can enroll in GoodRx provider mode here.
Medication-specific programs
There are certain organizations that provide specific medications at low or no cost to those without insurance. Some examples include:
Free HIV prevention medication through Ready, Set, PrEP
Free birth control through Planned Parenthood
Free vaccines through your local health department
The bottom line
There are ways to save on the cost of your prescriptions, whether or not you have insurance.
Choosing a low or no deductible insurance plan that covers your specific medications can help you save on prescription drug costs. Your healthcare provider may also be able to help get your medications covered by insurance through prior authorizations or step therapy programs. Manufacturer copay cards and free trial offers can also help save you money.
Patient assistance programs, charitable pharmacies, and discount cards can help provide free or low-cost medication to those without insurance. Some pharmacies also offer certain medications at a low monthly cost. And there are programs available that provide free medication for those with specific health conditions or medication needs, too.
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References
California Public Employees’ Retirement System. (2023). Homepage.
Charitable Pharmacies of America. (n.d.). Find a charitable pharmacy.
CMS.gov. (2023). Consumer Assistance Program. Centers for Medicare and Medicaid Services.
CMS.gov. (2023). Exceptions. Centers for Medicare and Medicaid Services.
Corallo, B., et al. (2023). Analysis of national trends in Medicaid and CHIP enrollment during the COVID-19 pandemic. Kaiser Family Foundation.
Dispensary of Hope. (n.d.). Dispensing site finder.
Dispensary of Hope. (n.d.). Homepage.
Healthcare.gov. (n.d.). Internal appeals. Centers for Medicare and Medicaid Services.
HIV.gov. (2022). Ready, set, PrEP. U.S. Department of Health and Human Services.
Medicare.gov. (n.d.). Costs in the coverage gap. Centers for Medicare and Medicaid Services.
Medicare.gov. (n.d.). Help with drug costs. Centers for Medicare and Medicaid Services.
Medicare.gov. (n.d.). Medicaid. Centers for Medicare and Medicaid Services.
Tolbert, J. (2023). 10 things to know about the unwinding of the Medicaid continuous enrollment provision. Kaiser Family Foundation.
U.S. Department of Health and Human Services. (2022). About the Affordable Care Act.
U.S. Department of Health and Human Services. (2022). Who’s eligible for Medicare?
