Prescription Drug Costs
For Your Benefits
For Your Benefits
Essential Strategies to Reduce Prescription Drug Costs
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Essential Strategies to Reduce Prescription Drug Costs

In 2021, the average per-employee cost of employer-sponsored plans increased 6.3%, the highest annual increase since 2010. This goes to show that self-employers are under enormous pressure to control medical costs for themselves and their employees. As a result, one of their top priorities should be to reduce prescription drug expenses.

According to a 2021 survey conducted by Gallup and West Health, approximately 18 million Americans said they were unable to pay for at least one prescription for their household. In this episode of For Your Benefits, we talk with Catherine Hall, Director of SentryHealth’s Prescription Drug Management Program, about the effect of rising drug costs and what employers and consumers can do to control spending. Together we discuss:

  • Brand vs. generic medications
  • Mail order pharmacies
  • What employees can do to save money
  • How employers can help employees reduce prescription drug spending

If you would like to learn more about how medical advocacy programs help lower prescription drug costs, check out this recent blog, “How a Medical Advocate Program Can Simplify Health Benefits“. You’ll discover how to simplify health benefits, lower medical costs, and increase employee health outcomes.

In This Podcast

Catherine Hall, RN, BSN

Catherine Hall, RN has been a registered nurse for more than 40 years and has been an Registered Nurse Advocate with SentryHealth since 2014. She is also a national speaker and has been recognized by the American Heart Association for her expertise in stroke care. Catherine currently serves as Director of the Prescription Drug Management program, educating participants about their medications and offering lower cost pharmacy alternatives.

Meghan Henry:
Hey everyone. Thanks for joining us for this episode of For Your Benefits. It has been a minute since our last episode, and it feels so great to be back and we’re glad you’re with us.

I’m your host, Meghan Henry, Director of Marketing for SentryHealth, an industry-leading integrated employee health company. In today’s episode, we are going to talk with Catherine Hall. She is the Director of our prescription drug management program, and we’re going to discuss strategies that employers and consumers can use to reduce medication costs. Hi Catherine!

Catherine Hall:
Hello there, how are you today?

Meghan Henry:
I’m well, thank you so much for joining us.

Catherine Hall:
Thank you for having me.

Meghan Henry:
Well, let’s see. Before we begin, I’d love to hear a little bit more about you and what you do at SentryHealth as part of our prescription drug management program.

Catherine Hall:
Well, I am the one that takes a look at all the claims and sees different prescription medications that my program may be able to benefit not only the patient but the company by reducing costs. So I look at all the costs.

I review that person’s prescription list because when I do the prescription management program, I’m not just looking at the drug they’re asking for, I’m looking at all their drugs to make sure that they’re compliant and these drugs are not interfering with each other. So it’s a big process to get a new client to review their medical history, go over their drugs, and then be able to assist them in any way that I possibly can.

Rising Prescription Drug Costs in the US

Meghan Henry:
All right. Very good. Well, let’s get started.

I know that you’ve got some great ideas on what we can do to sort of eliminate or at least reduce some of these prescription drug costs. I want to start out with an interesting statistic that I read recently. There was a 2021 survey conducted by Gallup and West Health, and they said that around 18 million Americans say they weren’t able to pay for at least one prescription for someone in their household.

Catherine, talk to me about why we’re seeing such rising costs of medication in the US?

Catherine Hall:
I can tell you a couple of reasons. Our medication costs have tripled in the last eight years.

Meghan Henry:
Oh gosh.

Catherine Hall:
Part of that is because we are the only country that doesn’t have regulations. Our drug programs are unregulated. So no government to help assist with pricing, to max out a price or anything. So they’re allowed to basically put a price on the medication that they feel is important to them, to recover for R&D, etc.. And the fact that it’s a new medication. An interesting fact with that too, is that as of January 1st this year, 832 brand name medications increase their cost by over 5%.

Meghan Henry:
Wow.

Catherine Hall:
832 brand names. Now, when you talk about a brand name, that’s because it’s under a patent with a brand name and then it can go to generic after the patents wore off. And I’m sure we’re going to get into more about the generic and the brand later. But another thing that is important to understand is that big pharma increases their prices every January and every June based on their return on investment. So your drug may cost and I’m just using easy numbers now.

Your drug may cost a hundred dollars in January, but when you go to refill it in July, it’s gone up to 600 and some dollars. So that’s because the company on regulation can do anything they want to, to make the prices of their drugs. So brand name companies raise them in January and July. And so it’s just interesting to know that we are the only country that has no regulations on drug costs. The only one. And our cost of our medication is three times greater than any other country in the world.

Meghan Henry:
Wow. That’s crazy.

Catherine Hall:
It is crazy.

Meghan Henry:
That reminds me of the… I don’t know if you saw it, the guy, the “pharma bro” guy who was arrested, but had purchased some drug that was an inexpensive drug for consumers to use and then bought it, raised the cost like 6000% or something crazy, and then basically priced it to where nobody could even pay for it or use it anymore.

Catherine Hall:
Right.

Meghan Henry:
So it sounds like it, I mean, it’s not regulated like you said.

Catherine Hall:
No. So let’s look at insulin. Insulin is probably the most purchased drug in the United States.

When we first had insulin many years ago and before it got bought out by another big pharma country, insulin cost about $35 a vial. That was it.

Meghan Henry:
Wow.

Catherine Hall:
$35 a vial. Then we were allowed to release the patent, and sell it to another company that said, “Oh my gosh, look at all these people that are using this drug. Look at the money we can make if we increase the price.” Drug companies will also raise the price if they do a different packaging. There is a different price for insulin in a vial versus insulin in a pen. And so those rates and those drugs are astronomical.

EpiPens is another one. Used to be able to get EpiPens for like a hundred dollars. I take an EpiPen. My last prescription cost me $353 for an EpiPen. Now, to me, those are the things that this country is using on a daily basis. Those essential medications, not that I’m saying that other meds aren’t, but I’m looking at who uses the most of these in the United States?

Meghan Henry:
Which are usually chronic conditions, diabetes things like that.

Catherine Hall:
That is correct. Diabetes, anything like that. I happen to have a latex allergy and I’m allergic to bees. So I have to have an EpiPen with me wherever I go.  And I can understand where people say, “I couldn’t afford this drug.” I understand that. Because like I said, my EpiPen went up astronomically. If I was on a very tight budget, then I’m sure that I would have to sit with my husband, spouse, and significant other, and discuss which Peter are we robbing to pay Paul so that we can get this medicine. So that our son doesn’t get sick. That’s where my program comes in because I have many different avenues that we can research and look for medication reduction in cost. So I’m sure we’re going to touch on that too unless you’d like me to go ahead with it right now.

Brand Name vs Prescription Drugs

Meghan Henry:
One of the things I know you mentioned generic drugs, I’d like to talk a little bit about generic versus brand name drugs. You touched on a little bit about why there’s a difference in pricing, but could you dig into that a little bit deeper? So what is the difference between the two?

Catherine Hall:
Well, sure. Brand medication and generic medication work the same. The difference is that brand medication is held under a patent for so many years. Once that patent expires, then any pharmaceutical company is able to purchase that drug and make it generic.

Meghan Henry:
So then there’s competition.

Catherine Hall:
Then there’s competition. Exactly. And so we have to wait through the processing time and the patent. And many times I’m like, “Okay, their patent ends in 2023, just another year and we can do this.” But if they can’t do generic and brand is the only available, then, of course, I would really want our company to be able to come to me and say, “Catherine, what can you do for me?” Generic drugs typically cost 80 to 85% less than brand drugs.

Now, the other thing is that the trademark laws say that a brand and a generic cannot look the same. So if you were taking a brand-named drug and it came off a patent and we were able to purchase it as a generic medication now, then you’re going to see an 80 to 5% decrease in cost because we’ve now made it generic.

So when we look at brand names, is this the best medication for this patient? Not just because it’s a brand new drug and it just came out on the market and there are 50,000 commercials on the television about it. And our patients are trying to tell our doctors how to treat us. It needs to be that we’re looking at, okay, I understand this new drug is out, but we need to try this other drug first, such as a step therapy to see if the drug that is not as expensive, works as well. If it does not, then you’re right. We would have to go to the brand for them.

What happens with generic when I say it may not work for them, is there is a 0.002% difference in some of the ingredients, in a generic and a brand once you mark, you take it out of the patent and put it into a generic. There are people in the United States that are highly sensitive to that. I will tell you that is probably a 0.01% of the United States population that cannot take anything but brand.

So we work with the doctors and we work, I do, I should say, I work with the doctors. I call them. I say, “This is the drug. What can we do? Where are we at?” So I’m getting involved with the patient care, building that relationship with the physician and the patient for this. Generic drugs are also heavily regulated and they go through a rigorous review process once the patent is over. So our goal is always generic, brand if we don’t have a choice or there is no generic yet. And this is the best drug for the patient.

My big thing in all of pharmacy is if that drug costs greater than a hundred dollars for a month or a thousand dollars for a month, you should be contacting somebody to help you see if there’s an alternative to the company spending a thousand dollars a month and the patient paying for the copay for this.

Meghan Henry:
Right, right.

Catherine Hall:
There are times I’ve had to say, “I cannot help you. It is not available in any other form. I cannot get it for either.” Then I start looking at patient manufacturing assistance and free medication. I have been able to get approximately six people, absolutely free medication through the manufacturer. Which means there is no payback to the company. They don’t owe anything on this. It’s free. And so to the company, but the patient gets what they want. But that takes a person who knows the process, who knows the paperwork, who knows what to say to these people. And so that’s another aspect of the job that I do, I actually directly speak to manufacturers.

Meghan Henry:
And I think it’s worth pointing out. I know that Catherine, you’re talking about our program specifically, there are other programs that with the SentryHealth program, you are a nurse, Catherine. So it’s not just we picked you up off the streets.

Catherine Hall:
Oh no, no, no.

Meghan Henry:
You’ve got clinical expertise. So not only do you know how to navigate all of this, but you also have that clinical background.

Catherine Hall:
Right.

Meghan Henry:
That I think is important for when you’re speaking to members or you’re speaking to whomever about all of these drugs that you got that clinical knowledge too. So I just wanted to point that out.

Catherine Hall:
Yeah. I probably should have said something. Yes, I am well-seasoned. I refuse to call myself old. I’m a well-seasoned nurse. I have 42 years of experience.

Meghan Henry:
Experience. There you go!

Catherine Hall:
In multiple facets of the medical practice.

Meghan Henry:
Perfect.

Catherine Hall:
That’s a good explanation of the difference between a brand and a generic, why we have to wait and what can we do if we can’t wait?

How to Lower Prescription Drug Costs

Meghan Henry:
All right, perfect. Catherine, there are people. Well, I would say most everybody’s worried about drug costs. I think there are people who are taking some medications that they just really can’t afford them. So what are they doing? They are perhaps maybe instead of taking two pills a day, they’re taking one pill a day, or maybe they’re getting prescribed a drug and they’re looking at it and going, I can’t afford it all. I’m just not going to take it.

Catherine Hall:
Right.

Meghan Henry:
So then what happens is they end up back at the doctor, and they end up in the emergency room. They end up with all of these unnecessary issues simply because they can’t afford these drugs. And so I’m curious to know, let’s say that we’ve got a member who is struggling to pay for medications. What are some things that they can do and what are some things they shouldn’t do? Maybe from a clinical perspective, a financial perspective. I think that I’d like to see both sides of that coin.

Catherine Hall:
Sure.

Meghan Henry:
What they can and cannot do?

Catherine Hall:
Well, here’s the thing you should never do. And that is stop taking your medication.

Meghan Henry:
And it seems very obvious and very clear but I think…

Catherine Hall:
But it’s not.

Meghan Henry:
Yeah. I mean…

Catherine Hall:
And again, when you’re looking at financials and you’re saying food for my children or this medicine that costs…

Meghan Henry:
Absolutely.

Catherine Hall:
… this amount of money, guess what every mama and daddy in the world are going to do? They’re going to feed their children and not take their medicine.

There are programs out there like GoodRx that have coupons out. I use GoodRx a lot because if you look at even your copay, sometimes on GoodRx, you can get the entire cost of the medication less than your copay. And so simple care is another one. I use those types of things. You can certainly ask your physician’s office if they have samples for you to use now.

Meghan Henry:
And would you suggest, is it always worth asking, is there a generic? Let’s say your doctor prescribes, whatever Xeljanz, I’m just thinking of what I see on… Excuse me, on TV. Is it appropriate to say, is there a generic for this drug?

Catherine Hall:
There is. That is an appropriate question for you to ask. And the new pharmacy regulation and laws is that the pharmacist is supposed to notify the patient if there is a generic medication available. I’d like to say that happens all the time, it does not.

Meghan Henry:
Right.

Catherine Hall:
But you can certainly get ahold of the pharmacy that you have with your company. And they can tell you what’s on the formulary. They can tell you, this is the place to get your meds, et cetera, et cetera. They’ll be able to assist you with that. Like I said before, there’s also patient assistance programs where anybody in the pharmacy business, anybody in HR, anybody in can assist somebody in pulling up GoodRx and helping them look for their medications.

If they’re looking at getting medications through a patient assistance program, that does take a little bit more, but your pharmacy company may also be able to help you. And that again is part of what I do for this company.

So you never want to stop taking your meds. I will say this. There are times that you can get some medication that’s 50 milligrams and you’re supposed to take 25 milligrams and due to cost, you can get those and split them in half and take half each day. So that’s going to help you.

90-day vs 30-day Prescriptions

Catherine Hall:
Another huge thing on cost is 90 days versus 30. Please go to 90 days. It’s the least expensive for your copay it’s the least expensive for anything else. Less time for you your employees will have more compliance because they’re not having to run to the pharmacy every single month to go get those meds. They come in and for goodness sakes, for the HR directors and brokers and things like, please, please have them use your mail service.

Meghan Henry:
Yeah.

Catherine Hall:
Because that also decreases cost. The patient doesn’t have to go anywhere. They get it delivered to their door. And so again, you’re doing everything you can possibly do to make sure that you have given them all the tools they have to be compliant.

Meghan Henry:
Yeah. I’m on a 90-day medication and it’s delivered to the door. I don’t worry about refills. It just automatically handles all of it.

Catherine Hall:
Right.

Meghan Henry:
I know in the past when I’ve had a pick-up, life gets in the way, and if you’ve got to get to the pharmacist, but you’ve got three other things to do. Sometimes you just put that at the bottom of the list. So I think having it delivered to the door is so convenient.

Take Advantage FSA and HSA if Offered

Catherine Hall:
Well, and the other way you have, if your company has an FSA or an HSA, please use those. That money’s coming out of your pocket. Don’t just leave it, sit there. My sister had an HSA and I said, she was all worried because she’s going to have to pay for something. I’m like, “Don’t you have an HSA.” And she goes, “Yeah.” And I said, “Well, then pay for your Advair D with your HSA that’s what…” She’s like, “Duh.” We tend to forget. There should be reminders from HR that every once in a while, “Don’t forget you have an FSA or an HSA.”

Meghan Henry:
Man education. I know that I have come across so many people that just don’t understand.

Catherine Hall:
No.

Meghan Henry:
Don’t understand what it’s for. Don’t understand when to use it, how to use it, what it can be used for. So I think education is important as well.

Catherine Hall:
It is. And I think that’s another thing that companies can do most companies have an intra departmental communication of some sort. Those could go out on a monthly basis. Those reminders, those, “This is the difference between an FSA and an HSA. Don’t forget to use that. Do you need help with your prescriptions? Come see somebody.” Something like that so that we educate.

The Difference in Tier Costs – Educate on Pharmacy Formulary

Catherine Hall
The biggest form of education that you can do is post your pharmacy formulary. Post it, explain it, because most people don’t understand the difference between a tier one, tier two, tier three, and tier four. I don’t know. Do you know the difference between all those?

Meghan Henry:
I do not.

Catherine Hall:
Yeah. So tier-one is on formulary. It’s like a generic. Tier two is like a brand that could be on the formula. Tier three is, it’s a generic that is not on the formulary. And then tier four, are your humongous expensive chemotherapies, et cetera.

That’s all right. It’s just that education of explaining to them so that when they get a medicine, they can go to their insurance website, look up the med and know what they’re going to pay. Is it a generic? And then they can say to their doc, “That’s a little expensive, and is there something else?”

Meghan Henry:
And I think that a lot of times people think that their physicians are doing that work for them. That they’re looking for the least expensive medication, they’re looking at the formulary. They’re not, right?

Catherine Hall:
Oh no.

Meghan Henry:
I mean, they’re prescribing whatever they think is the best medication or whoever-

Catherine Hall:
Yes. Exactly.

Meghan Henry:
Million different reasons, why?

Catherine Hall:
A million different, and the thing is that and I get this all the time with my patients too. Why doesn’t my doctor know that this and this? Your doctor has in a day’s time, 50 people that come through his office, with 50 different diagnoses, with a possible 50 different kinds of insurances, with 50 different kinds of pharmacy formularies. You are the one that is responsible for that. You as the patient are responsible to make sure that you’re getting drugs that are in the formulary, that you’re doing the generic, that you’re following through with things because that doctor and that office cannot do all that for you anyway, shape or form.

The Importance of a Prescription Drug Management Program

Catherine Hall:
So you have to depend on an advocate, you have to depend on your pharmacy company to help you, et cetera, to help you through that maze of where do I go? How do I do it? And then be able to know that the doctor’s office they’re the ones that are treating you, but they don’t do all that background stuff.

Meghan Henry:
Sure. And I think what’s cool about the program that we have Catherine, if someone is prescribed something and they are wondering about all of those, they just have to pick up a phone and call and they get to speak to you, and you can help walk them through all of these things. Here, ask the doctor these questions. I know that they’ve prescribed this, but this would be a generic version. Where the step therapy, like you, talked there are other alternatives to this.

Catherine Hall:
Correct.

Meghan Henry:
I think often we know that there’s probably an alternative or maybe not, or maybe we know that I just can’t afford this medication. I don’t know what to do. I give up. I’m just not going to take it.

Catherine Hall:
Exactly.

Meghan Henry:
But in the case of this program, I can call you and say, “Help me. I can’t afford this. What are my options?”

Catherine Hall:
Exactly.

Discount Cards and Patient Assistance Programs

Meghan Henry:
And that leads me to another question. I know that you had mentioned GoodRx. There are discount cards. I know some of the pharmaceutical companies offer discount programs. Talk to me a little bit about some of the other programs that members or consumers can utilize.

Catherine Hall:
Well, again, there is the GoodRx and the simple care. There are different kinds of, you can go to the manufacturing, get a coupon. Sometimes the doctor’s office has things like that. But your biggest things are just being a well-educated consumer of your healthcare. And just little examples. If you take Crestor or rosuvastatin, which is for cholesterol. Your copay for a 90 day is roughly around $20. You can get it through GoodRx for 16 bucks. The entire 90-day dose-

Meghan Henry:
For 16.

Catherine Hall:
Less money for your copay, no money that the company pays. That is the total cost of your medication. If you’re taking something like citalopram for anxiety or depression, again, your copay for that, it’s probably between 40 and 60. You can get it on GoodRx for $9 and 89 cents.

Meghan Henry:
Wow.

Catherine Hall:
So those are things that people can help you with, watch the commercials for the GoodRx simple care, as pharmacy costs go up, which I told you if you remember correctly from the beginning, we talked about how the rise in pharmacy in the last eight years has been tripled in the last eight years. So this isn’t going to change people.

Meghan Henry:
Yeah.

Catherine Hall:
Unless we get government regulation. And the other thing you need to know is that Medicare has no control over drugs. If Medicare was able to negotiate prices, all of our prices would go down. But because this country allows no government regulations, nobody, nobody can work on this to get the prices down for competition.

Meghan Henry:
Right.

Catherine Hall:
So it’s a problem that’s going to be outstanding for quite some time, but just to let you all know there are avenues out there you can go to. You can call your pharmacy company. You can call your pharmacy at the store. A lot of times they have coupons under the dust that they’ve gotten and can do something for you. You can call your HR director to assist you with this, and there are many ways that it can help you and our company is set up so that we’d be more than happy to assist you in that if you’d like.

The Role of Benefit Advisors to Help Educate

Meghan Henry:
Perfect, perfect. Catherine, I know we’ve talked quite a bit about what consumers can do. I’d like to shift gears a little bit. We’ve got a lot of benefits advisors, and brokers, who listen to this podcast and they are helping their clients set up health plans, prescription drug plans, and things like that to help their employees. What advice can you give benefits advisors as far as what can they do to help their clients, their employer clients to tackle these rising drug costs?

Catherine Hall:
Sure. Well, the first thing that’s very important is to have a pharmacy report. Because if you don’t have a pharmacy report, you’re just taking blindly what everybody gives you at the end of the month is what your pharmacy cost was. So you truly do need a pharmacy spreadsheet that says, this is what we paid for pharmacy. The second thing you should do is look at your top 50 drugs. 50 high-cost drugs.

The third thing you should do is then check your formulary for those 50 high-cost drugs. And then you can get with a pharmacy company would say, “Well, this is the patent’s going to go off, or this is going to happen.” You can get involved with a pharmacy management company like us, that will help you with that. Take that and say, “Here’s where I could find this and less expensive for you.” But your biggest thing is that we tend to just accept whatever report we get. Here’s the pharmacy, you spent 1.3 million and you’re like, “What?”

Meghan Henry:
Yeah.

Catherine Hall:
HR directors and brokers have to get a handle on pharmacy. Not prescribing, understanding cost, understanding generic, understanding patient assistance, and patient copay programs. They have to be educated so they can also direct their employees to the right place. Being educated and allowing you to know what’s going on with pharmacy. One company I had, gave me their pharmacy report. I looked at it and I said, “Oh.” They had a person on a brand medication that there was a generic available and nobody had switched the prescription. So this company had spent $3,200 a month on this drug not realizing there was a generic out.

Meghan Henry:
For one person?

Catherine Hall:
For one person. And I was able to take that-

Meghan Henry:
Incredible.

Catherine Hall:
… find it. I got a HIPAA form signed by the patient. I called the doctor, talked to him, we got her changed right over, that drug cost of $3,200 a month went down to 700.

Meghan Henry:
That’s amazing.

Catherine Hall:
And that should, you have to have a team person that helps you because there is no way a broker or an HR director can be well versed in everything.

Meghan Henry:
Sure. Sure.

Catherine Hall:
So make sure that the pharmacy company that you’re contracting with is open to talking, giving you information, to giving you pharmacy costs. If you have a pharmacy that says, “I’m not going to give you your pharmacy cost,” then you have a problem.

Meghan Henry:
Yeah. Yeah.

Catherine Hall:
Because then there is absolutely nothing you can do about that to make a change.

Meghan Henry:
Right. Catherine wrapping up here and I really appreciate you joining us today. This has been such a great conversation. I’d love to hear, do you have any advice for employers? I know you’ve covered some of that bits and pieces here. Is there any final piece of advice or anything that you’d like to share based on your expertise in the program that you’ve been running with us?

Catherine Hall:
Well, I just think that, again, the biggest thing we can do is have a handle on what our pharmacy costs are for your company. And then the biggest thing is again, understanding the formulary I may be able to assist your employee. Having a management program in your backseat, it’s kind of like, and I’m not like tooting my own horn, but maybe a little. But having someone that does what I do, now takes that pressure off of you.

Meghan Henry:
Sure, sure.

Catherine Hall:
And you’ve got one phone number. Give this phone number to your members. I take care of everything. So educating your employees, knowing your formulary, and being able to know your pharmacy prices is how you are going to be able to handle rising pharmacy costs for your company.

Meghan Henry:
Very good. Catherine Hall, thank you for joining us today. This was fantastic. Really appreciate it.

Catherine Hall:
Thank you very much. It was a pleasure.

Meghan Henry:
Awesome. This has been such a great conversation, and I really appreciate you sharing your strategies on how to reduce prescription drug costs. Hope that you listeners are taking away some of this great information as well.

That does it for today’s episode of For Your Benefits. Thanks to everyone for joining us. If you like what you heard today, please don’t forget to subscribe to our podcast. And if you’d like to learn more about SentryHealth and our prescription drug management program, along with our other integrated health management programs and services, visit our website at www.sentryhealth.com. See you next time.

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