How to Discuss Cost and Coverage Before Filling a Prescription

Imagine this: you leave your doctor’s office with a new prescription, excited to start feeling better. But at the pharmacy, the pharmacist says your copay is $320. You didn’t expect that. You didn’t even know your plan had a $500 deductible this year. So you leave the prescription on the counter. You’re not alone. About 22% of people skip filling prescriptions because of cost, according to 2023 GoodRx data. That’s not just inconvenient-it’s dangerous. Skipping doses because of price can lead to hospital visits, worse health, and even higher long-term costs.

The good news? You don’t have to guess. You can know exactly what you’ll pay before you ever walk into the pharmacy. And it starts with a simple conversation-before the prescription is even written.

Ask Before You Write

The best time to talk about cost isn’t at the pharmacy counter. It’s in the exam room, right after your doctor says, “I’m going to prescribe this.” That’s when you have the most power to change things. Once the script is printed, your options shrink. But while it’s still just an idea, your doctor can swap it out, adjust the dose, or suggest a generic.

Don’t wait for your provider to bring it up. Most doctors don’t. Only 15% of patients report having a cost conversation during their visit, even though 30% struggle to afford their meds, according to JAMA Internal Medicine. You’re not being rude-you’re being smart. Say something like: “I’m on a tight budget. Can we talk about what this will cost me?” Or: “Is there a cheaper option that works just as well?”

Doctors aren’t trained to know every drug’s price, but they know how to find out. Many now use tools like Surescripts’ Real-Time Prescription Benefit (RTPB), which shows up right in their electronic health record. It tells them your exact copay, whether the drug is on your plan’s formulary, and if there’s a lower-cost alternative. If your doctor doesn’t use it, they can still call your insurer or check online during your visit.

Know Your Plan’s Formulary

Your insurance plan doesn’t cover every drug. It has a list-called a formulary-that tells you what’s covered and how much you pay. These lists are divided into tiers. Tier 1 is usually generic drugs, costing $5-$15. Tier 2 is preferred brand-name drugs, maybe $25-$50. Tier 3 is non-preferred brands, $50-$100. And then there’s specialty tier-some drugs cost 25%-33% of the total price, with no cap. That’s where you can get hit with $500 bills for one prescription.

Before your appointment, log into your insurer’s website and search for your medication. Look for the tier, copay, and whether prior authorization is needed. Some plans require your doctor to prove the drug is necessary before they’ll cover it. If you find out it’s not covered, you can ask your doctor to pick something else-or start the prior auth process right then.

Medicare Part D plans must cover at least two drugs in each category, but their formularies vary wildly. In 2023, 78% of them used tiered pricing. Commercial plans? Even more complex. The average plan in 2024 covers over 3,250 drugs across five or six tiers. That’s overwhelming. But you don’t need to memorize it. Just check your specific drug.

Use Tools to Compare Prices

There are free tools that show you exactly how much a drug costs at different pharmacies-even with your insurance. GoodRx is the most popular, with 70% market share. SingleCare and RxSaver are also reliable. Just type in your drug name, zip code, and insurance (or choose “without insurance”), and you’ll see prices at CVS, Walgreens, Walmart, and local pharmacies.

Here’s how it works: a patient in Toronto used GoodRx to check her blood pressure med. Her insurance copay was $120. GoodRx showed the cash price at Walmart was $18. She paid $18 and saved $102. That’s not a trick. It’s legal. Pharmacies often sell drugs cheaper to cash-paying customers than they’re reimbursed by insurers for the same drug.

Don’t just use these tools after the fact. Bring the printout or phone screen to your doctor. Say: “This drug costs $18 cash at Walmart. Is there a version like this that my plan covers?” Your doctor might be surprised too-and willing to switch.

Understand Your Deductible and Out-of-Pocket Limits

January through March is the worst time to get a new prescription if you have a deductible. Most people haven’t met theirs yet. In 2023, the average individual deductible for a marketplace plan was $480. If your drug costs $150 and you haven’t paid $480 in medical bills yet, you pay the full $150. No discount. No copay.

Medicare Part D changed that in 2025. Starting this year, beneficiaries pay no more than $2,000 out of pocket for all prescriptions annually. That’s a big deal. Before, people could hit $8,000 before catastrophic coverage kicked in. Now, once you hit $2,000, your plan covers the rest. And insulin? Capped at $35 per month. Always.

Commercial plans don’t have this cap. That’s why some people pay $1,000 a month for a specialty drug with no end in sight. If you’re on a commercial plan, ask: “Is there an annual out-of-pocket maximum for drugs?” If the answer is no, you’re at risk. That’s when you need to push harder for alternatives.

Ask About Payment Plans and Assistance

Medicare now offers a Prescription Payment Plan. Starting in 2025, you can pay your drug costs in monthly installments instead of one big bill at the pharmacy. This helps if you’re on a fixed income. But you have to enroll before September-if you wait, there aren’t enough months left in the year to spread out the payments.

Even if you’re not on Medicare, ask your doctor or pharmacist about patient assistance programs. Drugmakers like Pfizer, AbbVie, and Johnson & Johnson offer free or discounted meds to people who qualify based on income. These aren’t hidden secrets-they’re listed on the manufacturer’s website. Your pharmacist can help you apply.

And don’t forget mail-order. Many plans offer 90-day supplies through mail-order pharmacies at lower costs. One patient saved $180 a month on his diabetes meds by switching from 30-day refills at CVS to 90-day mail-order. That’s $2,160 a year.

What If You’re Already at the Pharmacy?

It happens. You’re at the counter, the price is higher than you expected, and you’re stuck. Don’t walk away. Ask the pharmacist: “Can you check if there’s a lower price using a coupon or cash pay?” Many pharmacies will run the price through GoodRx or SingleCare in real time. If the cash price is lower, they’ll let you pay that instead.

Also ask: “Can you call my doctor and ask if there’s a generic or alternative?” Pharmacists can often send a message to your doctor’s office right then and there. In 2023, the American Pharmacists Association recommended pharmacists initiate cost conversations when a patient’s out-of-pocket cost exceeds 2% of their monthly income. That’s $80 for someone making $4,000 a month. If you’re over that, you have every right to ask for help.

Why This Matters More Than Ever

Drug prices keep rising. The U.S. spent $621 billion on prescriptions in 2023. Out-of-pocket costs made up 18% of that. And formularies are getting more complicated-more tiers, more restrictions, more surprises.

But the system is changing. The Inflation Reduction Act forced transparency. Medicare plans now have to show you your expected costs before you fill a prescription. EHR systems are required to show real-time cost data by 2026. This isn’t just a trend-it’s becoming the standard.

And when patients ask about cost, they’re 37% less likely to skip doses, according to the Journal of General Internal Medicine. That’s not just about money. It’s about health. It’s about living longer, feeling better, and avoiding emergency rooms.

You don’t need to be an expert. You don’t need to know insurance jargon. You just need to ask. “How much will this cost me?” That’s the first step. Everything else follows.