You go to the pharmacy expecting to pay $20, $40, or maybe $75 for your medication.
Instead, the pharmacist says:
“Your total is $287.”
You check the prescription. It’s the same medication. Same dose. Same pharmacy.
So what happened?
A prescription price can increase for several reasons, and the first price you hear isn’t necessarily the price you have to pay.
Before you put the medication back or pay hundreds of dollars out of pocket, there are several things worth checking.
First: Don’t Assume the Pharmacy Made a Mistake
It’s easy to assume the pharmacist entered something incorrectly when a medication suddenly costs more.
Sometimes that’s the case.
But prescription prices can change because of factors involving your:
- Insurance plan
- Deductible
- Formulary
- Copay or coinsurance
- Pharmacy network
- Manufacturer savings program
- Prescription quantity
- Prior authorization
- Medication coverage
- Insurance plan year
- Pharmacy benefit manager (PBM)
The pharmacy may simply be processing the prescription according to the information currently available to them.
The important question is why the price changed.
Ask the Pharmacist Why the Price Increased
This should be your first step.
Don’t simply ask:
“Is this the cheapest price?”
Instead, ask:
“Can you tell me why the price is this high?”
You want to determine whether the price is being driven by insurance or whether you’re being charged the pharmacy’s cash price.
Ask:
- Is my insurance being applied?
- Is this medication covered?
- Is it on my plan’s formulary?
- Did I reach my deductible?
- Is the pharmacy in my insurance network?
- Is there a cheaper generic?
- Is there another covered version?
- Is there a discount program available?
- Is the prescription being processed correctly?
Sometimes a simple billing issue can explain a surprisingly high price.
Check Whether Your Insurance Changed
One of the most common reasons prescription costs change is a change in insurance coverage.
Your health insurance plan may have changed its:
- Formulary
- Drug tiers
- Copay structure
- Coinsurance
- Deductible
- Preferred pharmacies
- Prior authorization requirements
This can happen when you change insurance plans, when a new plan year begins, or when your insurer changes how a medication is covered.
For example, a medication that previously cost you $25 might move to a higher tier and suddenly cost significantly more.
You may still have insurance.
But having insurance doesn’t necessarily mean your prescription will be inexpensive.
Check Your Deductible
Your deductible can have a major impact on what you pay for prescriptions.
Some plans require you to pay a portion or all of certain prescription costs until you reach a deductible.
That means you could see something like:
January: $400
February: $400
March: $50
The medication didn’t necessarily become cheaper.
You may simply have reached the point where your plan’s cost-sharing changed.
This is particularly important with expensive medications.
If your prescription suddenly becomes much more expensive at the beginning of the year, check whether your deductible has reset.
Check Your Drug’s Formulary Status
A formulary is the list of medications an insurance plan covers and the terms under which they are covered.
Insurance companies can place medications into different tiers.
For example, a plan might have:
- Tier 1 — Preferred generics
- Tier 2 — Preferred brand-name drugs
- Tier 3 — Non-preferred drugs
- Specialty tiers — High-cost or specialty medications
The exact structure varies by insurance plan.
If your medication moves to a different tier, your out-of-pocket cost could change.
And sometimes the medication isn’t removed from the formulary entirely it simply becomes more expensive for you.
Ask About a Generic
If your prescription is a brand-name medication, ask whether a generic equivalent is available.
You can ask your pharmacist:
“Is there a generic version of this medication?”
But don’t make the switch yourself.
Your doctor or pharmacist can determine whether a generic equivalent is appropriate and available for your prescription.
Generic medications can often cost significantly less than their brand-name counterparts, but availability and pricing vary.
Ask Whether There’s a Different Medication
Sometimes the issue isn’t the pharmacy.
It may be the medication your insurance plan prefers.
Your doctor may have prescribed Medication A, but your insurance may prefer Medication B.
In some situations, your doctor may determine that an alternative medication is medically appropriate and more affordable.
Don’t stop taking your medication or switch medications on your own.
Talk to your doctor or pharmacist about your options.
Check Whether You Need Prior Authorization
Another reason a medication may suddenly become expensive or unavailable through your insurance is a prior authorization requirement.
Prior authorization means the insurance company requires additional information before agreeing to cover a medication.
The insurer may ask your doctor to demonstrate that certain criteria are met.
If the authorization isn’t approved, you may be facing a much higher out-of-pocket price.
If this happens, ask:
“Does this medication require prior authorization?”
If it does, contact your doctor’s office and insurance company to understand what needs to happen next.
Check Your Pharmacy
Your pharmacy can make a difference too.
Some insurance plans have preferred pharmacies where certain medications cost less.
For example, your prescription might cost:
Pharmacy A: $175
Pharmacy B: $75
Mail order: $50
The medication hasn’t changed.
The difference may be the pharmacy’s relationship with your insurance plan or negotiated pricing.
Before transferring a prescription, however, make sure the pharmacy is legitimate and that the pricing you’re being quoted applies to your specific prescription and insurance coverage.
Don’t Assume the Cheapest Cash Price Is the Same as Your Insurance Price
This is an important one.
Sometimes a prescription can have:
Insurance price: $120
while the pharmacy’s cash price or a legitimate discount program might be lower.
But there are important considerations.
A cash purchase may not count toward your insurance deductible or out-of-pocket maximum, depending on the circumstances and your plan.
So don’t automatically choose whichever number is lowest without understanding how the purchase affects your overall prescription coverage.
Ask:
“What is my insurance price, and what would I pay if I didn’t use insurance?”
Then compare the options.
Look for Prescription Assistance Programs
If your medication remains too expensive, this is where prescription assistance programs may become relevant.
There are different types of assistance, including programs offered by:
- Pharmaceutical manufacturers
- Nonprofit organizations
- Foundations
- Government programs
- Other assistance providers
Eligibility varies.
Some programs are designed for uninsured or underinsured patients.
Others may have specific requirements relating to income, insurance status, diagnosis, medication, or other circumstances.
Having insurance doesn’t automatically mean you can’t qualify for prescription assistance.
That’s a common misconception.
What If You Have Medicare?
Medicare beneficiaries can also experience significant changes in prescription costs.
Your out-of-pocket cost can depend on:
- Your Medicare plan
- The medication
- Your plan’s formulary
- Deductible
- Copayment
- Coinsurance
- Pharmacy
- Coverage stage
- Eligibility for additional assistance
If your medication suddenly becomes more expensive, don’t assume that you’re stuck with the new price.
Review your plan’s drug coverage and ask whether additional assistance programs may be available.
What If Your Prescription Is Suddenly Hundreds of Dollars?
If your prescription went from $25 to $400, don’t panic—and don’t immediately decide you simply can’t afford it.
Work through the problem systematically.
Step 1: Ask the pharmacist why the price changed.
Step 2: Confirm that your insurance was processed correctly.
Step 3: Check your deductible and drug tier.
Step 4: Ask whether a generic or alternative medication exists.
Step 5: Check whether another pharmacy has a lower contracted price.
Step 6: Ask whether prior authorization is required.
Step 7: Look into manufacturer or patient assistance programs.
Step 8: Ask your doctor whether an appropriate lower-cost alternative exists.
Step 9: If necessary, investigate additional prescription assistance options.
The key is to find the reason for the price increase before trying to solve it.
Don’t Stop Taking Your Medication Because You Can’t Afford It
This is perhaps the most important point.
If you can’t afford your prescription, don’t simply stop taking it, reduce your dose, or stretch your medication without talking to your healthcare professional.
Skipping doses or changing how you take a medication can have serious consequences depending on the medication and your medical circumstances.
Instead, tell your doctor or pharmacist:
“I can’t afford this medication. What options do I have?”
They may be able to identify an alternative medication, adjust the prescription, help with authorization, or point you toward an assistance program.
Why Prescription Prices Can Be So Confusing
One of the frustrating things about prescription pricing is that there isn’t always one simple price.
A medication can have different prices depending on:
Who is paying
Insurance, Medicare, cash, or an assistance program.
Where you purchase it
Different pharmacies can have different pricing arrangements.
What insurance plan you have
Different formularies and negotiated prices apply.
Where you are in your deductible
Your out-of-pocket cost can change during the year.
Which version of the medication you receive
Brand and generic versions can have very different costs.
Whether you’re eligible for assistance
A qualifying assistance program could substantially reduce what you pay.
That’s why simply asking:
“How much does this medication cost?”
doesn’t always tell you what you will actually pay.
The Biggest Mistake: Assuming the New Price Is Final
If you’ve been paying $30 for a medication and suddenly you’re told it’s $250, your first reaction may be:
“I guess that’s what it costs now.”
Don’t assume that.
The new price may be legitimate, but you should still investigate why it changed and whether another option exists.
You may discover:
- Your insurance wasn’t applied correctly
- Your deductible changed your cost
- A generic is available
- Another pharmacy is preferred
- Your doctor can request prior authorization
- Your insurance prefers another medication
- A manufacturer assistance program is available
- A patient assistance program may be available
- Another legitimate savings option exists
The answer won’t always be “yes.”
But it’s worth asking.
The Bottom Line
A sudden increase in prescription cost can be frustrating especially when you’re taking the same medication you’ve been taking for months or years.
But don’t automatically assume you have to pay the new price.
Start by figuring out why the price changed.
Then look at your insurance coverage, deductible, formulary, pharmacy, generic alternatives, and potential assistance programs.
And if the medication is still unaffordable, don’t simply stop taking it.
Ask for help.
There may be options you haven’t considered.
Affordable Prescription Assistance
At Affordable Prescription Assistance, our goal is to help people understand their options when prescription medications become difficult to afford.
If the price of your medication has suddenly increased, you don’t have to assume that paying full price is your only option.