Your Guide to Prescription Savings
I know that managing prescription costs is a key part of your healthcare. This page is designed to help you understand your options, find savings, and make informed decisions about your medications. To assist you in this process, I have compiled a list of valuable prescription resources. This includes information on PRAM's programs, popular services like GoodRx, how to obtain manufacturer coupons, and other assistance programs that can help lower your out-of-pocket costs.
PRAM: Your Partner In Prescription Savings
To help you manage and lower the cost of your prescriptions, PRAM provides access to several unique programs. Each program is tailored to a specific need, from securing a $0 copay on common medications to finding assistance for expensive specialty drugs. Learn more about the savings opportunities available to you through each PRAM program:
ExclusiveRx
ExclusiveRx is a program that provides access to a list of over 260 medications at a zero-dollar cost. These are typically acute care medications that are commonly prescribed. This program also often includes access to non-insured virtual services like vision and hearing screenings. It's a great option for individuals who want a simple, transparent way to get common medications with a $0 copay.
Key Benefit: $0 cost for medications on the ExclusiveRx formulary.
Best for: Individuals with high-deductible plans or those who need commonly prescribed acute care medications.
RxBoost
RxBoost is a program specifically designed to help people manage the high cost of specialty drugs. Specialty drugs are very expensive medications used to treat complex or chronic conditions like multiple sclerosis, cancer, or rheumatoid arthritis. The program works by having a dedicated Patient Advocate who acts on your behalf to find the best possible savings. They will help you find and enroll in manufacturer savings programs, copay assistance, or patient assistance programs to bring down your out-of-pocket costs.
Key Benefit: Access to a patient advocate to find and manage savings on high-cost specialty drugs.
Best for: Individuals taking expensive brand-name specialty medications.
CostCare Rx
CostCare Rx is designed to give you a predictable and affordable price on your prescriptions. This program uses a 'lesser of' pricing model, which means you pay either your copay or the PRAM-contracted network rate, whichever is lower. This ensures you always get the best available price within the network. It also provides access to a drug look-up tool so you can compare prices at local pharmacies before you go.
Key Benefit: 'Lesser of' pricing ensures you always get the lowest cost between the network rate and your copay.
Best for: Anyone who wants a simple, effective way to get consistent savings on a wide range of medications.
Lyric Lean
Content: "Lyric Lean is a specialized program that focuses on weight loss, often including access to GLP-1 medications like Ozempic, Wegovy, and Mounjaro. This program is typically a monthly subscription service that combines medication with personalized support from a clinical team, including dietary and nutrition coaching. It is an all-inclusive program that helps you manage a comprehensive weight-loss plan.
Key Benefit: A holistic approach to weight loss that includes medication and clinical support.
Best for: Individuals seeking a comprehensive, medically-supervised weight loss program that may include GLP-1 medications.
How Your Health Insurance Covers Prescriptions
Health insurance plans use specific terms and structures to determine how much you pay for your medications. Knowing these terms can help you predict your costs and make the most of your pharmacy benefits. Here are some of the most important concepts to understand:
Formulary (or Drug List): This is a list of all the prescription drugs your health insurance plan covers. Most formularies are "tiered," meaning they separate drugs into different cost levels. To find out if a specific drug is covered and what tier it falls under, you can usually look it up on your insurance company's website or member portal.
Tier 1: Generics: These are the lowest-cost medications. They have the same active ingredients as brand-name drugs but are often priced much lower.
Tier 2: Preferred Brand-Name: These are brand-name drugs that your plan has a special agreement with. They cost more than generics but less than non-preferred brands.
Tier 3: Non-Preferred Brand-Name: These are more expensive brand-name drugs. Your plan may cover them, but at a higher cost to you.
Specialty Drugs: These are high-cost, complex medications used to treat serious conditions like cancer or multiple sclerosis. They typically require prior authorization and have the highest out-of-pocket costs.
To find out if your medication is covered and what the cost will be, log in to your health plan's member portal. You can search for your drug in the 'Pharmacy' or 'Formulary' section.
Quick Tip: Formularies can change. Always confirm your coverage and cost with your insurance or pharmacist before you go to the pharmacy.
What to Do If a Prescription Is Denied? Your insurance company may deny coverage for a medication. This can happen for several reasons, such as the drug not being on your plan's formulary, a lack of 'medical necessity' on file, or a requirement for prior authorization. If this happens, you have the right to appeal the decision. Here are the key steps you can take to challenge a denial:
Contact Your Doctor: This is the most crucial step. They can provide the necessary documentation and support to make your case. Often, a denial is simply a request from the insurance company for more information.
Ask for a "Letter of Medical Necessity": A letter from your doctor's office explaining why the denied medication is the best or only suitable treatment for your condition can be very powerful. This letter can address the specific reason for the denial.
Work with Your Doctor's Office to Submit the Appeal: Your provider's office staff often has experience with this process. They can help you gather and submit the required paperwork, medical records, and the letter of medical necessity to the insurance company.
Follow Up and Keep Records: Keep copies of all correspondence, including letters, forms, and notes from phone calls. Be aware of the deadlines for filing an appeal, as they are time-sensitive.
By following these steps, you can significantly increase your chances of having a denied prescription covered. Remember, you have the right to this process, and your doctor's support is your greatest asset.
GoodRx and Other Prescription Saving Options
GoodRx
GoodRx is a prescription discount service that provides free coupons for medications. It is not an insurance plan and does not replace your health insurance. Instead, it offers a way to pay a discounted cash price for your prescriptions.
How it works:
You can visit the GoodRx website or use their mobile app to search for your medication.
Enter the drug name, dosage, and your location to see a list of discounted prices at pharmacies near you.
You can present the GoodRx coupon or a screenshot of it to the pharmacist. They will use the information to apply the discount.