Prescription drug costs will remain high, even in many health insurance exchange plans

2013

Today I visited my local pharmacy for my annual flu shot (where I also previously received pneumonia and shingles immunizations) for “free.”

While there a man came to the counter to pick up a prescription called in for his wife. The first thing the pharmacist said was, “This isn’t covered by your plan … and it’s expensive.” “How much?” the man asked. “$502” was the reply. The look on the man’s face said it all; a combination of shock and fear. “Is there anything I can do?” the man asked. “I would call the doctor and see if there is a less costly alternative.” suggested the pharmacist. If there had been a generic, state law required the pharmacist to offer it, so that was not an option. That two-minute experience really brought home that health care is far from “affordable.”

For those folks who hope that Obamacare is going to change that, there is disappointment on the horizon. The health care law limits the amount that a patient is required to pay out-of-pocket to $6,350 a year for an individual and $12,700 for a family, but there are no specific requirements associated with prescription drugs. Some plans will only pay 50% of the cost; others 70 or 80%. In the case of the man above, even if his plan covered the drug, his cost would have been $100 or more.

This means patients who use a number of prescription drugs or very expensive drugs will pay significant costs up to their out-of-pocket limit. Consumers must weigh these costs against their plan premium and out-of-pocket limits.

The best way to deal with these costs is to use generic drugs whenever possible, ask your doctor to prescribe drugs on the plan formulary and if applicable, use the plans mail order pharmacy. Nevertheless, prescriptions are going to remain a major expense for many Americans.