A small sign taped to the counter at the Friday Harbor Drug Store explains to customers that “If you have any questions regarding the price of your prescriptions, please don’t hesitate to ask.” If a customer is looking for a way to potentially pay less for their prescriptions, they should pay heed to the sign.

Medicare, Medicaid and private insurance companies each have their own restrictions for payment, in addition to each person’s individualized plan that affects how much a medication costs. According to a Consumer Reports article, some pharmacies can be bound by contract to first try and bill the claim through a patient’s insurance company unless the customer asks for a different option, as is the case at Friday Harbor Drug, as well as Ray’s General Store and Pharmacy on Orcas Island.

Asking questions

In some cases there are cheaper alternatives to the price of a patient’s medication. According to Cristina DuVall, pharmacy manager at Friday Harbor Drug, pharmacists cannot offer these cheaper options unless a patient inquires, because limitations put on them by contracts and laws. Their intent, said DuVall, is to keep pharmacists by being influenced by drug companies and choosing a medication for a patient that might not be the right fit.

“So there has to be a line then to show that we’re not swayed by any one company in any way, or have any kickbacks for any particular company,” DuVall said. “And that’s the best way to do it, is to be objective and it has to come from the patient’s request. We’re not permitted to offer any incentives or price breaks for patients unless they request them.”

But DuVall said that they automatically run a geriatric discount for patients ages 65 and over that takes 10 percent off their bill. Sometimes, though DuVall says rarely, paying cash or credit for medication can be cheaper than a persons copay on their insurance.

One discount that can be available for patients depending on the drug are manufacturer coupons that come directly from a drug company’s website that offer discounts.

These are for brand-name drugs that don’t have any cheaper generic forms, but sometimes can’t work in conjunction with Medicare and Medicaid insurance plans.

“Unfortunately,” DuVall said. “Those are the people who would really benefit from them.”

“We can’t automatically apply those,” added Noah Atchley, lead technician at Friday Harbor Drug. “They have to ask for more information on why its expensive.”

Patients looking for manufacturer coupons should never give out their phone number or personal information, since those coupons are scams to get money from the pharmacy or the patient. Instead, only take coupons directly from the drug companies website, or when in doubt, contact the company or local pharmacist.

Donut hole

Unbeknownst to some, Medicare has four different parts, A, B, C and D. Only Medicare Part D covers drugs and medication. One unexpected trip-up that patients with Medicare Part D may find when trying to figure out their insurance is the donut hole.

The donut hole is a coverage gap that can occur when a person reaches a certain limit to coverage. That amount changes year to year. When the person is “in” the donut hole, they have to pay directly until they meet their deductible and get “out” of the donut hole and are covered by Medicare again.

“A lot of people don’t know about this, or when that’s going to happen, because they don’t know how much they’ve spent so far,” DuVall said. “Or they have an unforeseen expense that puts them into the donut hole and they haven’t been there before, or they started a new plan and don’t know the details of that plan.”

Atchley said in his experience it can range from $2,000 to $4,000 in out-of-pocket expenses before they are covered again, and that it varies depending on a person’s plan, how much they pay monthly and who is on the plan.

According to DuVall, patients may pay a higher premium to lower their copays and extend out when the donut hole will occur.

“This type of plan is best for someone who has maintenance medication and can plan how much to pay,” DuVall said. “But those who qualify for Medicare Part D are often 65 or older or disabled in some way, they don’t often know what the future will hold. They may have a heart attack this year and you can’t plan for that. It’s really unfortunately a disservice to our elderly population.”

Run for your money

Paying cash or credit for generic medication can be cheaper than copay depending on a person’s insurance plan, though DuVall pointed out that those “in” the donut hole should continue to bill towards their insurance, or else it will take longer to get “out” of the donut hole.

The stipulations for paying cash are more rigid in Medicaid plans.

“There is a law stating that they cannot pay cash unless all the appropriate channels have been gone through and denied,” Atchley said. “There is a form that is very specific that details every drug that they are paying for out-of-pocket so the state knows that we’re doing everything we can to make the state pay for it, and only when all of those options have been exhausted and it’s still not covered, that’s when the patient can pay cash for it.”

DuVall said that patients can always ask if the pharmacists can run the order as cash or run the order through insurance to see which one is cheaper, although that takes time that people often don’t have.

Insurance plans can shift, drug prices change day to day and coverage can be thoroughly confusing for patients who don’t understand their plan or formulary for what drugs are covered. And, since doctor’s don’t keep tabs on the price of drugs, they can often prescribe expensive brand names, or a drug that isn’t yet covered by a person’s formulary.

When that happens, pharmacists step in to either get a generic or get a prior authorization to get the drug covered, which takes time.

“I don’t know how to delicately put this, but a lot of time when people come up to the counter and they don’t see anybody in line, they just assume that it’s just count, pour and stick,” DuVall said. “There is a lot of behind-the-scenes thinking that goes with every prescription, and so it’s not just a matter of just grabbing a bottle off the shelf and putting a label on it.”