I Work in Healthcare — Here’s What You Need To Know Before Buying Prescriptions
Written by
Kerra Bolton
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Amen Oyiboke
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Prescription drugs often cost more in the U.S. than anywhere else, and most patients have no idea what they’ll actually pay until it’s too late.
Behind every prescription is a web of list prices, insurance negotiations, and cost-sharing rules that few people truly understand.
Here’s what healthcare insiders say about how the system really works and how to protect yourself when facing surgery, long-term care, or high-cost prescriptions.
The Truth Behind Prescription Pricing
Prescription drug pricing starts with the wholesale acquisition cost (WAC), often referred to as the “list price.” However, patients rarely pay this amount, and few realize the significant differences in the numbers.
“Like onions, there are layers to how pricing actually works,” said Wayne Luan, director and general manager, Life Sciences Solutions at Turquoise Health.
Luan explained, “The list price (wholesale acquisition cost, or WAC) is what the patient is responsible for paying. Oftentimes, the reported cost of drug is not the WAC. The majority of patients pay a small subset of the WAC, not the reported cost.”
The gap between the reported price and what patients actually pay is the root of much of the confusion surrounding prescription costs. Patients who understand this difference are better prepared to predict their real prescription costs.
Check Coverage Before Care
Surprise bills are most common with surgery, long-term care, and expensive prescriptions, making it essential to review coverage before care begins.
“It’s helpful to review your medical and pharmacy benefits beforehand,” Luan said. “The policy document is usually a PDF that’s 2-5 pages and gives you an idea of how much of a copay or coinsurance amount you’ll be asked to pay when you check in or after the procedure is completed.”
Reviewing important documents once or twice a year, especially during open enrollment, helps patients know which prescriptions are covered and what they might owe if they ever need a costly drug or procedure.
Ask Open-Ended Questions
When facing high medical costs, whether for a new prescription, long-term care, or a scheduled surgery, patients often feel cornered into accepting the first number they’re given.
However, Luan said that asking open-ended questions, such as “What are my options?” or “How would you handle this if you were the patient?” may shift the conversation.
“Either open-ended question gives the clinician or patient representative you’re working with the chance to provide options or solutions you may not know to specifically ask about,” said Luan.
In addition, asking open-ended questions could unlock solutions, such as access to cheaper generics, assistance programs, or alternative care approaches that still meet patient needs but at a lower cost.
Consolidate Prescriptions
Another overlooked way to save is by consolidating prescriptions under one physician. When a single provider coordinates all medications, they can review them annually and identify changes.
“It is always a good idea to have one physician coordinate all medications and review them once a year for changes, which happens less frequently than you would think,” said David Navazio, CEO of Gentell, a medical wound-care company.
Navazio said, “Newer versions or different drugs may be able to replace multiple prescriptions, thereby lowering costs. But you only get this type of evaluation if prescriptions are managed by one care provider.”
Look for Lower-Cost Options
Patients don’t always have to stick with the first price they’re given. Luan said taking a few small steps can uncover meaningful savings on prescriptions:
Ask about generics: Many states let pharmacies automatically substitute a brand-name drug for a generic version. If a competitor drug is on a lower formulary tier, it usually means a lower out-of-pocket cost for the patient.
Compare insurance versus cash: Sometimes, paying cash is actually cheaper than going through insurance. A quick question at the pharmacy counter can reveal the better option.
Seek out assistance programs: Copay cards and manufacturer assistance programs can significantly reduce costs. Many don’t require patients to meet an income threshold.
Shop before scheduling: If the prescription is tied to a planned procedure, patients with flexibility can compare costs across providers before locking in care
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