Industry Trends: When it Comes to Your Pharmacy Care – Advocate!

Industry Trends: When it Comes to Your Pharmacy Care – Advocate!

With more cost and deductible obligation falling on your employees and their families, one piece of advice that never gets old and quite frankly is still ignored by many is spending the time and effort to be your own advocate and actively get involved in your care plan with your providers.

The biggest advice we can provide to our clients, their employees and the general consumer base is that they have to be their own vigilant advocate!   Until fairly recently, many prescription copay plans provided comprehensive coverage which required nominal consumer dollar outlay.  Patients were sheltered from any incentive or reason to shop for alternatives or lower priced drugs that minimized out-of-pocket costs.    However, the pharmacy component of health care coverage has continued an uneasy, incremental pace, with ‘specialty’ medications being the fastest growing and most expensive segment of care – with skyrocketing costs for employers and ultimately consumers.  There really is no standard definition of specialty medications, but they have a couple of common characteristics.  First, they are very expensive.  Average monthly costs for specialty medication may amount to thousands of dollars, approximately ten times more than the cost of non-specialty drugs.  Second, they are difficult to administer–often by injection or infusion to treat complex, chronic, or rare conditions.  Some of the more common conditions utilizing specialty medications– Psoriasis, MS,  Rheumatoid Arthritis, just to name a few.  Specialty Medications in many cases have put patients in financial hardship and great economic distress where health plans shift considerable first dollar coverage to their plan consumers.

So, what can you do to moderate the cost and appropriate consumption of your prescriptions?

  • When prescribed a brand name drug, ask if there is a generic or less costly alternative.

Although this is one of the more common solutions, many consumers still do not question or advocate on their behalf with their healthcare professional (physician or pharmacist).  If a drug is necessary, ask how much it will cost.  Most doctors don’t regularly discuss drug costs with their patients. Therefore, consumers need to take the lead. When they do, ask whether a less costly drug might work as well. Generic drugs have the same active ingredients as brand-name ones, they’re regulated in the same way by the Food and Drug Administration (FDA), and they cost about 80 to 85 percent less. Many avoid asking their doctor this question thinking that their ‘doctor knows best’.  However, in most cases, there are a wide array of generic (and lower cost brand) alternatives that are therapeutically equivalent that a provider can prescribe.   If you make your provider (physician or pharmacist) aware that you are financially affected by higher cost medications, providers are inclined and open to evaluate and provide effective options that can save substantial dollars.  In many cases, providers just may assume your ‘insurance plan’ is paying the majority of the cost, if not all of the claim.   Asking about alternatives is the easiest and most effective way to reduce your spend.

  • Use Patient Consumer Sites that offer guidance, coupons, and rebate programs. These sites have been extremely successful in helping consumers successfully access the resources they need to significantly reduce their cost.

Patient consumer sites like Good and will show you the cash price for each prescription medication at multiple pharmacies.  Many common maintenance medications are included in the pricing exercise and you don’t need a membership for these sites.

The biggest advantage may be the significant savings acquired via coupons and rebates offered by the pharma manufacturer for those expensive specialty drugs.  These are available right on the site and can be easily printed.   Even if you don’t qualify for coupon savings from the manufacturer, many drug manufacturers offer Patient Assistance programs for uninsured or low-income patients. is a nationally-recognized resource for finding patient assistance program information and criteria.  Arranging for manufacturer coupons can be complicated and time-consuming.  And once again, consumers may be ‘outside their medical plan’ for this type of access which may or may not count towards plan deductibles, coinsurance, and maximums.   But in many cases, these alternatives can save significant dollars over the medical plan coverage.

Some other key advice is that if an individual is taking a medication, keep up to date and current with the prescription guidance.  While it may not seem like a big deal to skip doses, or forego filling a prescription altogether to save money, this could worsen the condition.   Without proper adherence to medications, conditions can worsen and lead to more serious and expensive health outcomes like hospitalizations, additional medications, missed days of work, etc.  Always talk to a provider before stopping a medication.  Keep up with preventive and well-check appointments.

Again, consumers need to be an advocate for their own health by working with their pharmacist and physicians to find the most affordable and effective medication solutions.

As your benefits partner, our job is to help you manage your Health and Welfare benefit responsibilities and find the right benefits and tools to support your employees.  Your KTB agent and/or Account Executive are prepared to discuss your full benefits package and help guide you through the health and wellness maze.