More than one-quarter of Americans struggle to afford medication — why some pay more and simple strategies that could save you hundreds

“This finding is alarming given that nonadherence, or not taking a medication as prescribed, can worsen chronic conditions,” GoodRx stated in its findings. High costs can force people “to make difficult choices between prioritizing their health and managing other essential expenses,” leading to increased costs in the long run.

It’s a problem that affects both the insured and uninsured.

Why insurance doesn't always help

One out of five Americans (20%) has at least one drug their insurance doesn’t cover, according to the GoodRx survey. Often when insurance doesn’t cover a drug, patients are on the hook for the full price, which can lead to financial strain and gaps in treatment. As for the price paid, on average, 23% of Americans who aren’t covered by Medicaid spend more than $50 per month out of pocket on their prescriptions.

The type of insurance plan you have is one determinant of how much you’ll pay for drugs. Those with a health exchange plan or private plan pay more than those on Medicare, Medicaid or Tricare, per the survey.

It also matters if your insurance is a copay plan or coinsurance plan. A copay stipulates that you pay a flat dollar amount when you pay for your prescription, while coinsurance means you pay a percentage of the cost. If the drug is expensive, coinsurance means you could end up paying a large chunk of it out of pocket.

And if you have no coverage, your options are even more limited. And that’s not an insignificant number of people: about 8% of Americans are uninsured, according to KFF (2).

Other reasons you might pay more

One other factor that could increase how much you pay for medication is something called formulary tiers. The formulary is a list of drugs covered by your insurance plan. The medications on this list can be categorized into tiers that determine how much you pay out of pocket. For example, lower-tier drugs generally have the lowest copays.

If you need a drug that’s not listed in the formulary, you’ll need to either get prior authorization from your insurance provider to have it covered or pay the entire cost yourself.

The practices of pharmacy benefit managers (PBMs) may also be driving some drug prices higher. PBMs essentially serve as the middleman in the drug insurance ecosystem. They work with insurance companies to help set and manage the formularies, negotiate drug prices with manufacturers, organize pharmacy networks and help with plan administration.

Some of these practices can lead to higher drug costs. Congress passed reforms on Feb. 3 to make PBMs more transparent in the hopes that this will help lower drug prices, although the effects may not be felt for years.

Some consumers may benefit from lower drug prices if they use preferred pharmacy networks. These are groups of pharmacies chosen by an insurer that charge the insurer’s policyholders lower copays. You have the option to choose any pharmacy, but you might pay less at a preferred pharmacy.

Strategies to lower your drug costs

There are ways you could potentially save money on prescriptions. One is simply to shop around. For example, WFTV Channel 9 found that “just driving to a different store could save consumers hundreds of dollars” (3).

You could ask your doctor to prescribe generic drugs, use drug discount cards or coupons, seek out manufacturer discounts and check if online stores might sell your prescriptions for less. It also can’t hurt to ask your pharmacist about ways to save money, such as purchasing monthly prescriptions in advance or buying in bulk.