Cutting out the middleman could dramatically lower your prescription costs

Sharon Downey says it’s tough getting old.

“I probably take 15 or 20 in the course of a day, so cost and medicines to me are very important,” Downey said.

While she has both health insurance and Medicare, Downey says they don’t really save her when it comes to prescriptions or medicines. So, she supplements those benefits with direct primary care membership.

Direct primary care means Downey pays her doctor, Dr. Rebekah Bernard, a monthly fee for unlimited visits. There is no insurance company involved, no deductible, no middleman. And that direct relationship is how Downey saves money on prescriptions.

“What Dr. Bernard saves me on the cost of medication more than covers the $75 that I pay her a month as a monthly fee,” Downey said.

Dr. Bernard, who owns Gulf Coast Direct Primary Care in South Fort Myers, also has a dispensary license and buys her generics directly from the supplier, passing the savings onto her clients.

“I can get pretty much any generic medication for my patients at just a fraction of the cost,” Bernard said.

Downey recalls a time when she went to the pharmacy for a drug and it was $350.

“I went in to see Dr. Bernard. I said this one’s costing an arm and a leg. She ordered that same drug for $60 a bottle,” Downey said.

Why the price difference?

Athos Health CEO and health care billing advocate Jon Hess says it’s not the pharmacy marking prices up, but a middleman called pharmacy benefits managers.

“Historically they’ve taken a huge profit,” Hess said.

Pharmacy benefits managers or PBM’s work like an arm of an insurance company, handling the “pharmaceutical stuff,” like what drugs will be covered and how much they’ll cost.

Direct primary care and cash price programs like GoodRX or Singlecare, either cut out PBM’s altogether or reduce the profit margin.

“They’re not getting the drugs from the manufacturer any cheaper than the employer plan is, or other plans out there. But they are not taking the same profit margin off the PBM insurance side,” Hess said.

Other ways to save

If you have insurance, Hess says to go to the drug company’s website and look for a copay card.

“For Humira, you see advertisements for Humira, they’ll pay up to $24,000 a year of your costs,” Hess said.

If you have Medicare, look for patient assistance programs or subsidy programs instead of copay cards or coupons. Under federal law, Medicare patients can’t use drugmakers’ discount cards or coupons.

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“You can still have substantial income. I found one where a family of two, as long as you made less $125,000 and you’re Medicare, they would cover the drug for free, your portion,” Hess said.

Also, ask your doctor about free samples.

Dr. Bernard, for example, helps manage Downey’s insulin costs by providing free samples.

Publix Supermarket also offers certain high blood pressure, diabetes medications, and antibiotics for free.

When comparing prices on cash sites, be sure to include Costco and Sam’s Club because neither requires a membership to purchase from their pharmacy.

What about generic?

Buying generic medications can save big bucks.

But Hess warns to check with your insurance company first. He says in some cases, just the name-brand drugs are covered.

“I see this more and more, and I didn’t hear about this two years ago,” Hess said.