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Prescription Drug Survival Guide

Jon W. Wahrenberger, MD

Part One: Purchasing Drugs Cost Effectively
Part Two: When You Simply Cannot Afford Your Medications
Part Three: Information about Medications
Part Four: Tips to Protect You

An often unappreciated aspect of illness is the cost of recommended medications.  For the patient without prescription drug coverage and especially those with limited financial means, the cost of prescription drugs can simply be overwhelming.  Not infrequently, this leads to difficulty in affording medications, and some tough choices.

There are, thankfully, a variety of ways to cut your medication costs - often dramatically so - without compromising your health.  This may involve working with your physician to choose a less costly medication, changing the way in which you shop, or taking advantage of a "Patient Assistance Program" which will help you obtain free medications directly from the pharmaceutical company.

This review is intended to help you on your journey to obtaining medications in a safe and cost-effective manner.  It should not be considered a substitute for the advice from your own physician, but rather an added resource to use in conjunction with your own doctor's recommendations.

Part One: Purchasing Drugs Cost Effectively

Just as most people shop around before purchasing a car or other expensive item, the cumulative cost of medicines used for long-term conditions makes it worthwhile to explore the various options before committing your retirement or food dollars to the closest pharmacy in town. In general, options include local pharmacies, internet pharmacies, and Canadian Pharmacies. Each option will be explored in detail.

Using Your Local Pharmacy

Your local pharmacy is often the quickest and most convenient place to get your medications. An added advantage of buying locally is the presence of a trained pharmacist who can warn you about drug interactions and provide counseling about potential side effects. The main disadvantage of the local pharmacy, particularly the smaller establishment, is higher prices.

When using a local pharmacy, keep in mind the following:

  1. Drug prices vary tremendously from pharmacy to pharmacy, so shopping around (using your telephone) can be very cost-effective. Keep in mind that one pharmacy may not offer you the best price on every drug, so be prepared to use more than one.
  2. In general you'll get a much better price per tablet if you buy 3 months worth or more of a medication at a time. If your physician hasn't done so, ask that your prescriptions be re-written for a quantity of at least 90 or 100 tablets at a time.
  3. Unless it has caused specific problems in the past, ask your pharmacist to provide you with a generic form of the drug, if available. In most states, in fact, a pharmacist is required to dispense generics if not specifically requested otherwise by the prescribing physician. See the discussion below for more information about generics versus name-brand medications.
  4. If you tend to travel a lot (or spend summers and winters in different locations) it's worth considering using one of the large national pharmacies such as Wal-Mart or K-Mart which keeps prescriptions on a centralized computer. If you should lose or forget your medications, you'll be able to get the prescription refilled at any store in the country without involving your doctor's office, and without delay.

 

Internet and Mail-Order Pharmacies

For the person without prescription drug coverage and particularly those on many drugs or with limited financial means, looking for lower cost medications from high volume pharmacies becomes necessary. Increasingly, this may involve purchasing medications through the Internet or via mail. The main disadvantage of purchasing medicines this way is that most (but not all) do not want to become involved with prescription drug insurance coverage.

The following are sites doing business primarily through the internet. To use them, it is necessary to have your physician call or mail your prescription to them. Prices tend to be excellent and shipping fees only minimal (Free - $6 per order). In general the best prices will be obtained if you order at least 90-100 tablets at a time.

Certified Pharmacies: [These on-line pharmacies have been certified by Verified Internet Pharmacy Practice Sites (VIPPS), part of the Nation Association of Boards of Pharmacy. Their use is highly recommended over non-certified pharmacies.]

Non-Certified Pharmacies:
  • RxUSA (http://www.rxusa.com)

 

For some tips and warnings about buying pharmaceuticals on-line, check out these site dedicated to buying pharmaceuticals on-line:

Canadian Pharmacies

For a variety of reasons, many medicines are sold at a substantially lower price to Canadian citizens. While importing large quantities of medications is not allowed, the Food and Drug Administration (and Customs and Immigration staff) will allow small quantities of medicines to be brought (or shipped) across the border from Canada into the US. In order to purchase medicines in Canada, however, it is necessary to have a Canadian physician prescribe the medicine. Until recently, this was possibly only by traveling to Canada and seeing a local physician.

Now, fortunately, some pharmacies in Canada are doing business via the internet and mail and have arrangements with Canadian physicians to officially prescribe a medicine for you as long as they are provided with evidence of your precription from a US physician and some brief medical information.

Keep in mind that these pharmacies will offer substantially better prices on expensive, name-brand medications and may offer generics where generics are not available in the US. The following table compares prices among some commonly prescribed medications in the author's practice. You will notice significant savings on name-brand medications and no uniform savings on generics.

Cost Per Month (U.S. Dollars) of Sample Medications from Various Sources:

 

  Wal-Mart K-Mart CVS.Com CanadaMeds CanadaDrugs
Sample Name-Brand Drug          

Lipitor 80 mg

107
123
112
76
80

Norvasc 5 mg

47
48
47
46
35
Plavix 75 mg
131
125
123
75
80

Altace 10 mg

55
52
50
34
27
Sample Generic Drug

Atenolol 50 mg

4
5
5
16
7

Metoprolol 50 mg
8
6
6
10
3

Lisinopril 20 mg

14
13
21
32
17

[All prices in above table represent monthly cost in U.S. dollars assuming 90 day purchase and administration of one tablet daily. K-Mart and Wal-Mart prices were obtained on phone 4/16/04 with respective pharmacies in West Lebanon, NH and remaining prices were obtained from web sites. All prices were rounded to the nearest dollar. CVS.com charged $1.95 per order for standard shipping and this was not included in above price. Cost of shipping for each Canadian pharmacy is about $10 per order (regardless of number of meds) and was not included in above pricing]

Medications can be purchased from Canadian pharmacies using a number of methods.  If you have a computer and internet access, your can compare prices, download necessary forms and initiate orders with a credit card on-line.  It will be necessary, however, for a valid US prescription to be mailed or faxed before your order can be shipped.  Alternatively, if you do not have internet access, you can contact any of the pharmacies using their toll free telephone numbers and complete the entire process using your telphone and mail service.  In addition, you have the choice of dealing with the Canadian pharmacy on an individual basis or taking advantage of a further reduction in price negotiated by the United Health Alliance (see below).

Sources of Canadian Medications: These are Canadian Pharmacies used by the author's patients and which appear to be reputable:

*Although all five listed Canadian pharmacies are certified pharmacies, only CanadaMeds and CanadaDrugs are certified by the North American Pharmacy Accreditation Commission (NAPAC). The NAPAC site offers more information on their standards and the significance of their certification. CanadaDrugs is also certified by IMPAC (www.na-pca.org/Impac/media_impac.html), the International Mailorder Pharmacy Accreditation Commision Pharmacy.

Legal Issues in Importing Medications from Canada

Some questions exist about the legality of importing medicines from Canada.  While it seems likely that such importations are technically a violation of the United States Federal Food, Drug and Cosmetic Act, the FDA has adopted an openly permissive policy about such importation if for personal use.  In their publication "Coverage of Personal Importations", the FDA states "FDA personnel may use their discretion to allow entry of shipments of violative FDA regulated products when the quantity and purpose are clearly for personal use, and the product does not present an unreasonable risk to the user.  Even though all products that appear to be in violation of statutes administered by FDA are subject to refusal, FDA personnel may use their discretion to examine the background, risk and purpose of the product before making a final decision."  For more information, visit the FDA's Coverage of Personal Importations.  To read the official U.S. Customs and Border Protection policy on medications and drugs, visit http://www.cbp.gov/xp/cgov/travel/alerts/medication_drugs.xml

As one further consideration , I am told that some states, particularly Florida and Arizona may have state laws that forbid importation of drugs from non-state-certified pharmacies.

New Hampshire's Canadian Drug Connection:

In early 2004 New Hampshire's Governor Craig Benson, aware of the skyrocketing cost of prescription drugs, evaluated the safety of importing drugs from Canada. Following both an on-site visit and laboratory evaluation of sample Canadian drugs, Governor Benson created a link on the Governor's website to a selected Canadian Pharmacy, CanadaDrugs.com, the only pharmacy accredited by both IMPAC and NAPAC.

Part Two: When You Simply Cannot Afford Your Medications

What can you do if you absolutely cannot afford the medications which have been recommened? What should you do if the demands for food and other necessities is competing with funds for medications? Here are some things to consider doing:

Let Your Physician Know About Your Difficulty in Affording Medications:

  1. Contact your doctor's office. He or she may have samples which can be dispensed and which might bridge you through a rough period. In general doctor's offices are given only small quantities of medicine samples and it is not realistic to expect a doctor to keep you supplied with any medicine long-term. Also keep in mind that the medication samples in the doctor's office are generally the newest and most expensive drugs on the market - while the use of such samples is great when they're free, they may not be the best drugs to be purchasing yourself if you are financially strapped. But this might buy you some time.
  2. Talk with your doctor about lower cost options, including the use of generics if they are not already prescribed, or switching to less expensive medications of the type you are taking.

Explore Patient Assistance Programs:

Most of the major pharmaceutical corporations have programs to provide drugs free of charge to patients with true need. Obtaining medications in this manner requires you participate in a program organized by your local hospital, clinic or doctor's office. Often it requires simply a letter from your doctor, a brief form to fill out, and an inquiry into your finances.  Here's some more information when considering this option:

  • Within New Hampshire, the Foundation for Healthy Communities coordinates the "NH Medication Bridge Program" and can steer you to a patient assistance program near you.  The program currently lists 41 sites.  Visit their web page (http://www.healthynh.com/) or directly download their "NH Prescription Assistance Guide", which lists participating prescription assistance sites and provides additional useful information.
  • Web-based help with Patient Assistance Programs: At least two web sites, run by not-for-profit organizations, can help you through this process and determine whether the manufacturer of your medicine participates in such programs or whether state resources are available to help you:
      • RxAssist - a national not-for-profit program supported by the Robert Wood Johnson Foundation.
      • HelpingPatients.Org - a new interactive Web site by PhRMA and 48 of its member companies. This site was designed to help you find patient assistance programs for which you may qualify. It also helps you determine whether you may qualify for a state program and provides acces numbers, web links, etc.
  • If you participate in such programs, be prepared for a delay up to 4-6 weeks before you're fully enrolled.  Since you may need to fill out certain forms on a regular basis, you might want to photocopy an unsigned and undated form so it can be easily resubmitted each time requested.

Explore Federal, State and Other Resources:

  1. Contact your state or community. The same people that provide assitance in other dire emergencies, can generally also provide you with assistance in getting you medications, either short or long-term. See the section below on "Helpful State Resources" for more information.
  2. Are you eligible for benefits through the Veteran's Administration?  If so, you may be able to obtain your medications through the VA with only a small co-pay.  Look into this. 
  3. Helpful State Resources:

    New Hampshire:
    For those eligible, New Hampshire Medicaid provides prescription drug coverage. To learn about the program and determine if you are eligible for benefits, call the Medicaid Administration Bureau at 1-800-852-3345 ext.4344 (toll free, in-state only) or (603) 271-4344.

For NH residents 65 years old or greater, the state is participating in a pilot program in which eligible residents are given a pescription discount card which will allow 15% (brand-name) to 40% (generic) discount on medicines purchased from participating pharmacies. You can learn more about the program from the National Prescription Administrators at: 888-580-8902 or 800-650-6729. The program's web site can be accessed at:

http://www.nh-rxdiscountprogram.com/index.html
The Foundation for Healthy Communities (mentioned above) can steer you to programs which may help you obtain medications.

Vermont:
In addition to assitance through the Medicaid program, the State of Vermont has a number of programs administered through their "Health Access Plan" which provide assistance in obtaining medicine for those with limited financial resources but not qualifying for Vermont Medicaid. These include:

VHAP Pharmacy Program

VScript Pharmacy Program

VScript Expansion Program

Pharmacy Discount Program (PDP)

Healthy Vermonter Program

To learn more about these programs, including qualification requirements, you can call (within VT) 1-800-250-8427. A brief overview of the programs, including qualification criteria, brochures and application materials can be viewed at:

http://www.dsw.state.vt.us/districts/HAEU/VHAP_RxVScript_Brochure.htm

Part Three: Information about Medications

The generic vs. name-brand drug debate

In spite of the many myths surrounding the use of generic drugs (most of which are promoted by pharmaceutical companies desiring you to purchase their higher priced medications), generic drugs contain exactly the same acitve ingredients as the brand-name drugs. Makers of generic drugs must submit them to the FDA for approval. Among other things, the FDA assures "bioequivalence", which means that it is absorbed at the same rate and appears in the blood stream in a similar period of time (and at similar levels) as the pioneer drug. The chemical stability and quality of the manufacturing process must also be demonstrated. Not infrequently, the makers of generics are the same companies that produce brand name drugs.

It is important to realize, though, that while makers of generics must demonstrate chemical equivalence, they are held to slightly less strict standards than brand-name manufacturers in terms of the speed of appearance in the bloodstream, levels attained, and speed of elimination. For most medications this is unlikely to make any difference. For certain medications, however, the difference between therapeutic levels and toxic levels might be quite slim and small differences in blood levels may be clinically important. This might be true for heart rhythm drugs, for instance. For this reason, you should always check with your physician before switching to a generic drug.

Although the active ingredient in a generic is identical to that in a name brand drug, other chemicals used as fillers and for color may be different. It is remotely possible, therefore, that you might notice a difference.

What should you do? If a generic is available, it's likely to be much less expensive and equally effective. If your physician and pharmacist feel it is equivalent and safe, try it! If for some reason it doesn't appear to work as well, then go back to the name-brand medications. For many medications, particularly those that are still protected from patent infringement, no generics are available.

Keep in mind, also, that if you have insurance which covers prescription drugs, you may be forced to use generic drugs or make a higher co-payment when using name-brand drugs. If you've had definite problems with a generic (and not with the name-brand) drug, it's usually possible for your physician to insist that you receive only the name-brand drug.

 

  • If you'd like to read a review on the equivalence of generic drugs from the FDA, read FDA Ensures Equivalence of Generic Drugs (http://www.fda.gov/cder/about/whatwedo/testtube-17.pdf"). You'll need adobe acrobat to open it.

Medicine Information Links

  • Clinical Pharmacology 2000 (http://cp.gsm.com) an excellent site with up-to-date information on prescription, over-the-counter, investigational, and herbal products. Requires free registration.
  • eMedExpert - Informational website dedicated to health and medicine. Drugs reviewsand comparisons, Brand/Generic name correspondence tool, PDR's Side effects index. The information is based on recent reviews and articles published in the medical literature and drug prescribing information approved by the US FDA.
  • Medline Plus Health Information (Drug Section) (http://www.nlm.nih.gov/medlineplus/druginformation.html) This is a good site with information provided by the National Library of Medicine.
  • MD Consult (Patient Education) (http://home.mdconsult.com/das/patient/view) A fairly extensive, non-commercial site with lots of information about drugs, medical conditions, etc.
  • Health Reference Center (http://infotrac.galegroup.com/itweb/dmcl_main) A searchable site with a collection of full-text reference books, pamphlets, and articles, plus references to additional articles.

Part Four: Tips to Protect You

Here are some recommendations to protect yourself from harm when purchasing prescriptions on-line or through the mail:

  1. Check with the National Association of Boards of Pharmacy (http://www.nabp.net/), (847) 698-6227) to determine whether a Website represents a licensed pharmacy in good standing.
  2. Never purchase a prescription drug from a company that does not require a physician's prescription or that sells drugs not approved by the FDA.
  3. Don't do business with sites that have no access to a registered pharmacist to answer questions.
  4. Don't do business with sites promising miracle cures.
  5. Don't do business with sites that do not provide a US address and telephone number.
  6. Some final drug safety tips:
    • Never break or split tablets unless scored or unless your phamacist tells you it's safe to do so. The timed delivery of some medications is dependant upon a coating placed over the active ingredient, and splitting such a medication may lead to an inappropriately rapid (and dangerous) entry of the medicine into your bloodstream.
    • Keep medicines in original containers so you won't get confused about the identiy and dosing
    • Enteric coated tablets, which contain a thin outer layer to delay absorption, should not be taken with milk or antacids; doing so may lead to premature dissolution within the stomach.
    • Never chew, crush or dissolve enteric-coated or sustained-release preparations.
If you would like to comment on these recommendations or have information you would like to share with others on this topic, please contact me.

Jon W. Wahrenberger, MD FACC
Section of Cardiology
1 Medical Center Dr.
Lebanon NH, 03756
jon.wahrenberger@hitchcock.org

 

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