As a consumer or employer navigating the complex world of prescription medications, one of the most frustrating questions we hear is, “How much is my drug copay?”

It seems like it should be a simple answer, but in today’s rapidly changing pharmaceutical and insurance landscape, it’s becoming increasingly complicated. Let us share our experience and what our clients can learn.

Gone are the days when you could confidently walk into your local pharmacy knowing exactly what you’ll pay for a prescription. Now, It’s like a guessing game every time you need to refill a medication.

Why? Because drug prices can vary wildly depending on a multitude of factors:

• The specific pharmacy you choose
• The insurance plan’s current formulary and tiers
• Whether the consumer is using a coupon or discount card
• The time of year (Deductible)

New Players Shaking Things Up

Recently, we’ve noticed many new names entering the pharmacy landscape, disrupting Pharmacy Benefit Managers and ultimately bringing transparency to a largely untransparent industry:

Mark Cuban Cost Plus Drug Company

Skeptical at first – a celebrity starting a drug company? But what we are seeing is the single greatest disruption in health care from Mark Cuban: They buy medications directly from manufacturers and add a flat 15% markup plus a small pharmacist fee. They are breaking the model of distribution and delivery of drugs in the USA and bringing transparency in pricing that is leading to total dissolution of the middle men. For some of my prescriptions, it’s actually cheaper than my insurance copay!

GoodRx

This app has been a game-changer for many. The ability to compare prices at different pharmacies in your area and even get discount coupons is powerful There will be times paying cash by using GoodRx is cheaper than going through insurance. Who would have thought? Crazy, and counterintuitive but accurate.

Even with these new options, navigating insurance coverage can still feel like solving a Rubik’s cube blindfolded. Your copays can change based on:

• Whether you’ve met your plan or RX deductible
• If the drug is considered “preferred” on the plan and what tier it falls into
• If you need prior authorization
• Whether you are using a specialty pharmacy or where you purchase

What’s a consumer to do?

Here is how end users and employers can guide their employees about managing drug copays:

1. Always ask questions: Don’t assume your copay is set in stone. Ask your pharmacist if there are cheaper alternatives or available discounts.
2. Use technology: Apps like Good-Rx can be incredibly helpful in finding the best prices.
3. Consider alternative sources: Look into options like Mark Cuban’s company, Amazon Pharmacy, Costco, or online pharmacies, but always verify their legitimacy first.
4. Talk to your doctor: They might be able to prescribe a cheaper alternative or a generic version.
5. Understand your insurance: It’s a pain but researching through and understanding your plan’s pharmacy benefits and formulary can save you money in the long run.
6. Don’t be afraid to shop around: Different pharmacies can have vastly different prices for the same medication. And, your health plan may encourage use of a certain pharmacy

The Bottom Line

So, how much is your drug copay? The honest answer is: it depends. The pharmaceutical landscape is changing rapidly, and consumers need to stay informed and proactive. While it can be frustrating to navigate, these changes also bring opportunities for savings. By asking questions, using available tools, and being willing to explore new options, everyone can take control of their prescription costs.