State Government Programs (Prescription Drugs at Low Cost)

Various state governments have programs to assist individuals with financial difficulties in obtaining prescription drugs. These programs are needed because many people make too much money to qualify for Medicaid. These programs are different, however, from the programs that most states have to aid individuals with specific diseases or conditions that can be very expensive to manage, such as AIDS, cancer, cardiovascular disease, and diabetes.

Presently, only about half of all the states have some type of program specifically designed to aid individuals with prescription drug costs. The eligibility criteria and services provided differ from state to state and from program to program. Appendix A summarizes the state assistance programs for those states that presently offer one. States are constantly adding new programs or modifying existing ones. To keep up with all the changes and to find out the specifics for the state in which you live, log on to the web site of the National Conference of State Legislatures at www.ncsl.org/programs/health/drugaid.htm.

These programs are usually designed for seniors (persons age 65 and older) on Medicare. However, certain individuals, including those with disabilities, such as blindness, can join. Eligibility is usually based on income and this varies from state to state. These programs are usually very comprehensive, that is, they cover a lot of prescriptions.

All of the programs have some form of cost sharing, which means that the patient pays for some of the cost of the medications. These costs come in various forms like copays and deductibles. A deductible is the amount you have to spend before the program starts helping you. So if, for example, you have a deductible of $200, you will have to spend $200 on medication in that year before you can start using the program. Some programs also have enrollment fees and some have premiums, which are amounts you pay to be in the program. Premiums are similar to what you pay to have insurance. So, in those states that have premiums, you will be charged a certain amount that you can pay over time just like you can with your car insurance.

To use the state prescription assistance program:

1. Obtain the phone number for your state’s program (see appendix A for the number).
2. Get an application sent to you.
3. Enroll in the program and obtain a card.
4. Present the card at the pharmacy when filling a prescription.
5. Get the drug with a copay or at a discount.

Prescription Drugs at Low Cost

Individuals can acquire medications at a substantial discount to the retail price, in most cases, whether they have insurance or not. Using the programs described here, patients should be able to get the medication (or an equivalent substitute) at a discount and will realize significant savings, especially if they are on medications for chronic conditions. The programs described are:

• State government programs
• Generic substitution
• Brand name substitution
• Use of the Internet
• Discount pharmacy programs
• Pill cutting
• Importing drugs
• Drug company discount programs

Refer to the flow chart on page 32 to see which program is best for your situation.

About Drug Vouchers

Physicians normally get samples through sales representatives from pharmaceutical companies based on their specialty and prescribing habit. The practice location also determines what type of samples they receive. For example, office-based physicians get more pills and less of the types of products that are used in hospital settings such as drugs given intravenously.

A growing number of hospitals and other health institutions are now banning the use of samples, however. The reasons range from the difficulty of maintaining proper handling and management of the samples as required by regulatory bodies to the effect of drug samples on cost. An alternative to samples is the use of drug vouchers. With drug vouchers, patients receive a coupon for the drug, which they take to the internet pharmacy to receive the medication for free. The drug company reimburses the pharmacy for the cost of the drug.

Drugs Samples

Samples are free medications provided by drug companies to physicians, to give to their patients. Samples are very useful, especially in acute disease states when the patient needs medication immediately and can’t wait to get a prescription filled in a pharmacy. Pharmaceutical companies provide samples to physicians to start new patients on the drug to determine if the drug might work for the patient before committing them on the drug long-term. Samples also create brand awareness and build product loyalty. Samples can save you a lot of money. Doctors, by law, cannot charge for samples. In many acute conditions, such as a routine strep throat infection or acute pain, the physician might have enough samples to cover the whole course of treatment. If your doctor, therefore, gives you a prescription and you can’t afford it, ask the doctor if he or she has free samples. Your doctor might have enough for the whole treatment or might have some to get you started and then you can fill the rest at the online pharmacy, hence saving you money. While samples are not ideal for chronic conditions, they nonetheless can be useful in chronic conditions as well. Your doctor might have "stock" bottles of medications. Usually samples are packaged to contain just a few pills to get you started on the drug. That’s why samples are also referred to as starters. For chronic conditions, some drug companies provide physicians with containers that have up to a month’s supply. Physicians have been known to sustain patients who cannot afford to buy medications for months on these stock bottles. There are many benefits to using samples:

• Samples are free. They have been used effectively by physicians to assist a lot of individuals who could not afford the price of the medication.
• Samples result in high compliance. Many individuals do not fill the prescriptions their doctors give them. With samples, however, the patient is getting the drug directly and has a higher chance of treating the condition.
• Samples help the doctor know if a particular medicine will work for a patient and if there are side effects that would make it wiser to switch to a different drug. Medicines do not all have the same effect on all patients, and other medications could be available for the same condition. By giving a patient samples for a short period of time, a doctor can determine if that patient should stay on that drug or try a different one.
• Samples help physicians become more familiar with new drugs. When a new drug comes out, the drug company promotes it heavily and gives out lots of samples. While the patients benefit from this new therapy, the physician has the chance to evaluate for himself or herself how the drug really works. It also allows the doctor to know if there are special patient types that the drug works better in, any special conditions or circumstances to keep an eye out for, and any dosage adjustments that need to be made.

Certain issues must be kept in mind as far as samples are concerned:

• Your doctor might fail to catch an important drug interaction. In a regular prescribing sequence, a patient receives a prescription from a doctor and uses a pharmacy to get the medication. With samples, the patient gets the medication directly from the doctor. In nearly every case, this works just fine. Pharmacists, however, play a role in catching medication errors and in checking for drug interactions. If a pharmacy is not involved, it makes even more sense to ensure that your doctor is aware of what medications you are taking, including herbal medicines. If you have any questions as to what you received, go back and ask your doctor or consult with your pharmacist. Another circumstance where a pharmacy can be of help is in the case where a medicine has been recalled because of safety or other concerns. If the pharmacy has a record that you are on the drug, at least another person besides your doctor can notify you.
• Samples might not be properly managed. Federal law, state law, and private regulatory bodies require the proper handling, storing, and accounting of samples. There have been circumstances, however, where samples were not being properly handled or patients were given medications that were no longer useful. Although this is rare, ask your doctor if you have any doubts. Also check the expiration date on the package you are given to ensure that the medication is still good. A word of caution, though, about expiration dates: expiration dates do not always determine when a drug stops working. So your doctor might give you a drug that has recently gone past its expiration day. Bring the issue up with your doctor. If the expiration day was not that long ago, your doctor may say it is fine to use.
• Be sure you are getting your sample from a person who is authorized to give you a prescription. While office staff members help the physician or prescribing personnel hand out medication, they can only do so with written orders from the prescriber. Be sure you are getting samples as a result of your doctor’s orders.
• Samples could cost you more money in the long run, because physicians give out samples of what they have and samples in physicians’ offices tend to be of new products that are usually more expensive than older drugs. So, if you have a chronic condition and you were started on an expensive product, although it was free at the beginning, staying on it might become costly in the long run. If you are given samples of an expensive medication, be sure the samples are enough to cover you for the course of the treatment. If not, ask your doctor if a lower cost drug is available, which, although you might have to pay for it, ensures that over time you come out ahead financially.

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Saving on Prescription Drugs When You Have Drug Coverage

If you have insurance that covers prescription drugs then you don’t have to worry about medication cost, right? Well, maybe or maybe not. Most probably, when you get a prescription from your doctor, you take it to your local pharmacy, and if you have managed care insurance, you pay a copay—your share of the cost. The online pharmacy then deals with the insurance company to get paid the other part of the medication cost. Most individuals have health coverage through managed care plans, and these plans provide prescription drug coverage with copays. The copays are usually fixed amounts, between $10 and $30, depending on what the plan designates in your contract. Usually the amount is fixed for a year, and that is how much you pay, regardless of the actual cost of the medication. So, if the medication costs $100 and your copay is $10, you pay $10. If your doctor prescribes another medication that costs $200, you still pay only $10. Your insurance pays the difference to the pharmacy. Many managed care plans are now developing different copays for members based on the plan’s cost for the medication. So, for example, a member might be charged a copay of $10 for the generic version of a drug but will have to pay a copay of $30 for the brand name.

There is a catch to the copay system, however. For you to pay only the copay, your doctor must prescribe a medication that appears on what is called a formulary, which is the list of medications that the insurance company has decided it will pay for. If your doctor decides that the medication that is the most appropriate for you is not on the formulary, he or she has to call the insurance company to justify its use. If the insurance company is not satisfied with the explanation, you will have to pay the full price of the medication.

If you have indemnity insurance that covers prescriptions, you pay for the medication and then submit a claim form to the insurance company to get reimbursed for all or part of the medication cost. In all of the above cases, the out-of-pocket costs are usually small and most people who need medications for an acute condition can easily manage the cost. It starts to be a bit more complicated and expensive, however, when an individual has several chronic conditions and/or is on several medications. Even when you obtain your medications with copays alone, if you have several chronic conditions such as high blood pressure, high cholesterol, and diabetes, and are on several maintenance drugs, these copays can add up pretty fast.

The first step in managing the cost of prescriptions is to determine if the disease is an acute condition or a chronic condition. Acute conditions are illnesses that usually come on suddenly and whose treatments require relatively short periods of time, from a one-time therapy to a month or two of medications. Examples of acute conditions are pain after you see a dentist, an infection such as a strep throat or an ear infection, or a cold. Managing these conditions is not as expensive because once the treatment regiment is completed, the disease is usually cured.

Chronic conditions, on the other hand, usually develop gradually and when diagnosed, have to be treated for longer periods. Chronic conditions like diabetes and high blood pressure have to be treated for longer periods of time, even for life. It is important to realize that with these conditions, you have to continue treating the disease even when you do not feel any symptoms. Many of these diseases have to be "managed" because we do not yet have cures for them. When patients fail to follow treatment directions like taking their medicine every day, the disease can become more complicated and more difficult to manage. The result is an even greater expenditure on healthcare. There are two strategies for managing the cost of prescriptions when you have coverage: mail order and samples.

Prescription Drugs and Healthcare Cost

Drugs today have not only caused us to live longer but they have also improved the quality of our lives. A lot of illnesses can be managed effectively with medications, reducing the need for hospitalization or nursing care. Thus, medications are cost-effective in managing our diseases. Newer and better drugs are being developed each year.

Many people, however, struggle with how to afford prescription drugs. The elderly, those 65 years old and older, are especially hit hard. This group, which is expected to double by the year 2030, uses about 35 percent of all prescription drugs. The classes of people most affected by the high cost of prescription drugs are:

• People who have no health coverage.
• People who have health insurance but their policy does not provide prescription drug coverage. This applies to seniors on regular Medicare since Medicare does not provide prescription drug coverage.
• People who have insurance coverage but are given prescriptions that are not covered by their plan. This applies to individuals with managed care coverage who have been given a prescription for a drug that is not covered by the plan.
• Individuals with prescription coverage, especially those on multiple medications, who face increases in their share of the cost of the drugs.

The debate over the cost of prescriptions is often complex and emotional. Drug companies are in the business of producing drugs for a profit, and they have done a great job in producing newer medications that work better or safer than older medications. It costs a lot of money, to the tune of over $500 million, to get a product to the market effectively.

The debate has always centered on how much these drugs should cost. Drug companies need to get back the money spent in developing a new drug, but more importantly, they need the profits to be able to have enough resources to fund the research to produce the next generation of drugs. Most of the new drugs used around the world are developed in the United States. This is because the U.S. market is the only market that allows drug companies to price their products using market forces as opposed to the government imposing price controls. This does not mean that drug companies can charge whatever they want. Market forces prevent them from doing so. Competition within the industry, either from other brands or from generics, when available, helps to ensure that drugs are not priced as much as the manufacturer might like.

Another market force in play is demand for the drug. Newer medications usually are safer or work better than older medications. The drug company might have to spend a huge amount of money educating the public about the drug, in the form of advertisements and consumer brochures, to create a demand for the newer medication. With greater demand, the company can charge a bit more, just as the manufacturer of any product might be inclined to do.

As stated in chapter 1, prescription drugs play a major role in secondary prevention. With most chronic diseases, the proper use of prescription drugs can effectively prevent or delay the need for institutional care, thereby saving a lot of money. Many individuals, however, do not take their medicine as prescribed or don’t take it at all. One of the biggest reasons for this is that these individuals cannot afford the medication. Chapters 4 and 5 address this problem. Whether you have insurance or not, whether you are rich or poor, you can always find a program that will allow you to have access to any medication, either for free or at markedly reduced prices. Using the programs described here, cost should not serve as an excuse, especially when you are dealing with the most important aspect of your life: your health.