Part 3 – Healthy Living for Life – Making Medicine More Affordable

– Glad you stayed with us A colleague of mine now joins us, Lisa Sather, Mountain-Pacific Quality House director of Clinical Pharmacy Services

Lisa will take a deeper dive into the drug formularies discussed earlier, including ways you can save money on medications Welcome, Lisa – Hi, Sara, thank you – Earlier in the show, Kimme talked to us about formularies What are they? – Yeah, that's a great question

So, most Medicare plans, providing prescription drug coverage, have a tiering structure that, really, kind of outlines prescription drugs and their pricing, so it usually goes from your least expensive to your most expensive, and usually broken out into four or five tiers So, usually what you see are Tier One medicines are gonna be your generic medicines Tier Two, your non-preferred generic medicines Tier Three, your preferred brand name medicines Tier Four, your non-preferred brand medicines, and then getting into Tier Five, your most expensive, are those specialty medicines, and sometimes, you know, a good example of those would be medicines for arthritis

People will recognize that, so those are your most expensive medicines And I think it's important to talk about, in order to get the most out of your prescription formulary, is to, really, know where your prescriptions fall, in that formulary, and ask questions of your provider You know, most medicines, anymore, are available generically, unless it's the newest, greatest medicine, and by mandate, generic medicines are as effective as brand name counterparts, so you really wanna know if a generic is appropriate for you You can typically get those for less expensive Pricing

If your physician or doctor thinks that you need to have something that's in a more expensive tier, you know, visit with them Sometimes, you're able to get an exception to get it at a lower cost sharing, if there's nothing else that is clinically appropriate available to you, and, so, that's just a conversation to have And I think it's also important to talk about when you select a Part D plan, you really need to pay careful attention to where your medicines fall within the tiers of that specific Part D plan, so you can know what your costs are going to look like – Does your physician know about the formulary when prescribing medication? – So, unfortunately, no That's a great question

Physicians see hundreds of patients per day, and in line with that, they're a different formulary for every prescription plan out there, so one idea is, really, to call your prescription plan and get a copy of the formulary that is your specific formulary, or go online Oftentimes, there are online websites you can sign in to, and bring that with you to your physician appointment so that you can discuss where the medicines you're taking are located in that, and come up with some ideas, and find the the least expensive alternative for you – [Sara] What if your physician doesn't have the time to review that formulary with you? – Yeah, that's a great question, because they're super busy, and so, this where you, as the patient, really need to engage in your healthcare You can call your prescription plan, discuss with a customer service representative, options, get a copy again, talk to your pharmacist They're a great and valuable resource, because they can help outline lesser expensive alternatives

Sometimes they'll even offer to call your physician and discuss – Can your insurance plan change your plan's formulary? – Sure As new drugs become available and new drug formulations become available, yes, you may see a formulary change These new drugs and formulations are evaluated against the clinical evidence, to see where they should fall into line, and so, that, oftentimes, will happen, and another example is if a new generic comes out, or if we find out, potentially, that there's a safety or efficacy concern, or if the plan determines that a formulary change would benefit the plan, in general, they may do that, but typically, for Medicare plans, you're going to see, at least, a 60 day notice before a formulary change is made – I've heard the term "quantity limits"

– [Lisa] Yes – What does that refer to, as it relates to a formulary? – Yeah, that's a great question So, most prescription plans will have a certain quantity of, say, dosage units that are allowed in a day's supply or a month's supply, so, one per day would be a maximum of 30 for a 30 day supply This is done, based off of the clinical evidence, and how the FDA has approved the medications So, that's really important, because, obviously, that goes to making sure that the medicines are being used safely and effectively for you

Sometimes exceptions are made outside of the maximum quantity limits, based upon the clinical situation, so, your plan, you can have your pharmacy or your doc talk with the plan to decide that It's also very important to note some medicines for cost effectiveness You'll have quantity limits, because there might be a uniform pricing across each quantity, each strength of that medicine, so, we wanna use the least number of dosage units to get the best pricing So, that makes it more cost-effective for the patient and the plan – "Preferred pharmacies" is another term found in formularies

What does that mean? – Sure, so, preferred pharmacies are a network of pharmacies that the prescription plan has negotiated with, in order to provide discounts that are then passed along to the consumer, and it can save you money If you go to an out-of-network pharmacy, you may end up having a higher copay if you use your ID card, then if you went to an in-network pharmacy, so it's very important to pay close attention to that – Can pharmacists help choose a lower priced drug at the point of fill? – Yeah, that's also a great question Yeah, they're kind of in a great position to do that, so it may not be accomplished right at that exact moment, but yes, if you fill your prescription, you're there at the pharmacy, and you realize it's going to cost hundreds of dollars, right at that point in time, have the conversation with your pharmacist and ask them if there's something that might be less expensive that would work for you The other part of that is to make sure that you don't pay for your prescription

Leave the pharmacy if you have a concern about cost, because once you leave the pharmacy, you're going to be stuck with it – [Sara] In the remaining seconds that we have, can you talk, briefly, about drug discount cards – Yeah – Good or bad? – Yeah, that's a great question So, drug discount cards often purport up to a 75% savings on prescription costs for you

Really, if you have a health plan, oftentimes, that's gonna be a better price for you because your insurer's already negotiated the discount If you don't, you can have your pharmacist check and see if it's gonna be a lesser cost for you, but it's just important to talk with your pharmacist about those options – [Sara] Thanks, Lisa, for that very valuable information – Absolutely – And thank you for tuning in today

I hope you found our show helpful This is such a complicated topic We hope to cover it further, on future shows Until next week, stay fit, stay well, and stay healthy for life, with Healthy Living for Life Take care

– [Narrator] Healthy Living for Life is brought to you by Mountain-Pacific Quality Health We'd love to hear from you If you have suggestions for future programs, visit our website, at MPQHForg, or call us at 406-443-4020 You can also catch us on YouTube by visiting our website and clicking on the YouTube icon

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