I Can’t Afford My Medication Even With Insurance - 7 Options to Know

Key Takeaways

If you are struggling to afford your medication even with insurance, some resources to help are prescription discount cards, Medicaid, Medicare, pharmaceutical assistance programs, and nonprofits.

Rising prescription costs in the United States are making both name-brand and generic drugs unaffordable for many Americans. Even people who have an insurance plan are finding that affording their prescribed medication is a financial strain on their budget. Many people are simply unable to take a prescription drug due to cost.

The lack of medication access due to cost can leave a medical condition untreated, putting your health at risk. If you are struggling to pay for your medications even with prescription coverage, there are programs that can help lower prescription costs or even obtain medications free. Please continue reading to find out more.

What happens if you can't afford medicine?

If you can’t afford medicine and don’t take it as prescribed, it can lead to a worsening of your condition, requiring hospitalization and, ultimately, severe health complications and even death. For instance, if you have chronic conditions such as diabetes, high blood pressure, or other cardiovascular diseases, serious health consequences will occur as a result of medication non-compliance. Besides drug side effects, the costs of prescription drugs are another cause of non-compliance.

Not keeping your blood pressure in check can lead to heart attack, stroke, and kidney failure. Uncontrolled diabetes can lead to heart disease, eye damage, nerve damage, skin problems, and kidney diseases, among other serious health complications, affecting your quality of life and lifespan.

Why is my medication so expensive with insurance?

Your medication may be expensive even with insurance because of the following reasons:

If you are enrolled in Original Medicare or a Medigap plan, it means you don’t have enough health insurance to cover prescription drug costs. In this case, you are required to pay for your prescription drugs.
Every health insurance plan has a list of prescription drugs that are covered by that plan. This is called the formulary. If your healthcare provider prescribes a drug that is not in your plan’s formulary, you are responsible for the full out-of-pocket costs of that medication.
Private health plans typically classify prescription drugs in their formulary into categories called tiers for cost sharing. Drugs in different tiers require different copayments or coinsurance. For example, your plan may specify that third-tier drugs require a copayment of $65 or coinsurance of 35%. If you are taking one of these prescription drugs, you will be responsible for this portion of the cost of the drug.

What happens if medication is not covered by insurance?

If a prescription drug is not covered by your health insurance plan, you have a few options available:

Talk to your doctor about taking a generic drug instead of a name-brand drug. Generic drugs contain the same active ingredient and are approved by the U.S. Food and Drug Administration (FDA) to treat the same health conditions as their brand-name counterparts. Generic drugs are equally effective, safe, and can be up to 85% cheaper than brand-name drugs.
If your health plan doesn’t cover certain prescription medications, ask them for a list of comparable alternatives that are on the plan’s formulary. You can also contact the pharmacy benefits manager (PBM) to start an appeal process, which will require detailed documentation from your healthcare team. In many cases, PBM would approve the appeal if they deem the medication as vital for your health and the benefits outweigh the risks.

How do you pay for expensive medication?

If you are having trouble affording your medication even with insurance, here are some other resources that can help you obtain lower-cost drugs.

Prescription discount cards

Drug discount cards such as BuzzRx, GoodRx, SingleCare, and Scriptsave WellRx discount cards can help you save money on your prescriptions at retail pharmacies and mail-order pharmacies if you are uninsured.

If you have insurance coverage, you may find that the discounted price of a medication after using your discount card at participating pharmacies is lower than your insurance copay. You can compare prices at leading retail pharmacies near you and purchase your medication at up to 80% off prescription costs. Learn more on our blog: “How Do Prescription Savings Cards Work?”

Medicaid

Medicaid is a government program for people with low income. All the states offer prescription drug coverage for eligible patients under Medicaid. You can contact your State Medicaid Office to check eligibility. If you qualify for Medicaid, you may be able to obtain drugs covered in the formulary as long as they are medically necessary, are ordered by a Medicaid-enrolled provider, the prescriptions are filled at a local pharmacy that is in the plan’s network, and you meet other requirements related to the drugs.

Medicare drug coverage

Medicare Part D includes prescription drug coverage, and this prescription drug plan can be added to Original Medicare. You can also join a Medicare Advantage Plan that includes prescription drug coverage in addition to medical care. You can save on Medicare Part D costs if you are eligible for the Extra Help program.

State pharmaceutical assistance programs

State prescription assistance programs (SPAPs) are government programs that provide financial assistance to certain eligible people to help pay for prescriptions. The coverage offered by different state programs varies.

Some SPAPs provide wraparound coverage for prescription drugs that are not covered by Medicare Part D. Some are for specific populations, such as elderly or disabled individuals.

Others provide assistance with prescription drugs for specific conditions such as AIDS, ulcerative colitis, or multiple sclerosis. Other state pharmaceutical assistance programs offer help to a wider range of people for a wider range of conditions.

Pharmaceutical company patient assistance programs (PAPs)

Drug companies sometimes offer their brand-name drugs at lower costs to qualified people through drug assistance programs. Check to see if you qualify for patient assistance programs or drug discount programs offered by the drug company that makes your prescribed medication.

You will need to check the individual websites of the pharmaceutical companies that make your prescription drugs to see if you are eligible for their patient assistance programs or manufacturer coupons.

These drug assistance programs from pharmaceutical companies have eligibility requirements, and the discounts offered may be different depending on whether or not you have health insurance.

Independent pharmacy programs

Many pharmacy chains such as CVS, Walgreens, and RiteAid offer prescription drug savings so that you can get the medications you need for less. It is also worth checking if mail-order prescriptions may be more affordable, as they sometimes include 90-day supplies at a lower cost.

Nonprofit groups

Some nonprofits offer free medicines or financial assistance programs for prescription drugs, insurance premiums, or copays to individuals and families with limited income. If you cannot afford prescription drugs, check if you qualify for an assistance program offered by a nonprofit.

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