INTRODUCTION

When people have a limited income, they sometimes stop taking some or all of the medicines they are supposed to take. For example, people sometimes try to make their medicines last longer by skipping doses or taking smaller doses. That’s understandable, given how expensive some medicines are. Unfortunately, people often don’t realize that stopping medicines or skipping or lowering doses to save money can cause serious health problems in the long run. Take, for example, people with a condition called coronary heart disease. If they cut back on their medicines, they are more likely to have a heart attack than people who take all their medicines. To make things even more complicated, people who skip or cut back on medicines often end up being prescribed more medicines, because their doctors think that the medicines they prescribed in the first place were not enough (such as with blood pressure or cholesterol medicines) [1-4].

If you are having trouble paying for your medicines, you should know that there are often ways to make medicines more affordable. If cost is an issue for you, tell your doctor, nurse, or pharmacist. He or she might be able to switch you to a less expensive medicine, or there might be other ways to cut costs, even if you don’t have insurance.

Don’t be embarrassed to bring up money. Many people have trouble affording their medicines. The key to finding a solution is to talk to your doctor, nurse, or pharmacist.

The tips for making medicines more affordable described here are meant for people who live in the US, but they might also apply to people in other countries.

ASK FOR GENERICS

Generic medicines are less expensive copies of brand-name medicines. They contain the same active ingredient as the brand-name medicine they copy, and they are subject to the same government rules about strength and purity.

One of the best ways to save money on medicines is to substitute your current brand-name medicines with ones that come as generics whenever it is appropriate to do so. There are a few different situations in which generic medicines might be appropriate for you:

• Brand name you take comes in generic form — If the brand-name medicine you take is also sold as a generic, you might be able to take the generic version of that medicine. In many cases, pharmacies will automatically give you the generic version of the brand-name medicine you are prescribed if it is available. For example, if you take the brand-name medicine Lipitor to lower cholesterol or treat a heart condition, an equivalent generic called atorvastatin is now available. The color and shape of generic atorvastatin pills might be different from the brand name version of the pills, but generics are tested to make sure they have the exact same active medicine as Lipitor. (See 'Are generic drugs as safe?' below.)
• A medicine in the same “class” as your brand name comes in a generic form – Similar medicines are grouped together into “classes.” All the medicines in one class work in roughly the same way. For example, the medicines in a class called “bisphosphonates” all slow down loss of bone in about the same way and lower the risk of having a serious hip fracture.
  
  Sometimes, if one medicine in a class is not sold as a generic, it is possible to take a similar medicine in that class or a related class that is sold as a generic. For example, the bisphosphonate medicines Actonel, Atelvia, and Boniva are sold only by their brand name and can be pretty expensive. If your doctor prescribes one of these, you might be able to take generic Fosamax called “alendronate,” which is also a bisphosphonate but is available for as little as $4 per month at “big” retail stores. This saves about $1500 per year on one medicine. (See 'Shop around, buy in bulk' below.)
• The brand-name medicine you take comes in a different way that is available as a generic – Some medicines are sold as brand-only because they come with a newer formulation that is still under patent. For example, if you take Coreg CR, a once per day heart medicine, you may be able to switch to generic Coreg, “carvedilol,” which is taken twice per day. This can save as much as $1600 per year. (See 'Shop around, buy in bulk' below.)
• The brand-name medicine you take contains two or more medicines that are each available as a generic – Sometimes medicines are sold as brand-only because they are the only product that combines two or more ingredients into one pill. In such cases, it’s often possible to take the individual ingredients in separate pills.

It’s not always possible or appropriate to switch away from a brand name. But when it is appropriate, it can save a lot of money. Any time you replace one medicine for another, make sure you learn what the new medicine looks like and which medicine it is replacing. People sometimes accidentally take the same medicine twice because the brand-name and generic pills look different, and they think they are taking two different medicines. (See 'How do I find out if I can switch to a generic?' below.)

How much can I save by buying generics? — On average, a 30-day supply of a “brand-name” prescription medicine costs about $140 a month without insurance coverage. A generic prescription costs about $35 a month without insurance. What’s more, the cost of a commonly prescribed generic medicine can be much lower than that, even just $4 per month, if you shop around. That means that switching to the generic could amount to a savings of more than $1600 a year on just one medicine. The price of generic drugs can vary widely from one pharmacy to another. It is important to price shop for generic medicines. (See 'Shop around, buy in bulk' below.)

Why do generic medicines cost so much less than brand-name drugs? — When drug companies develop a new medicine, they spend a lot of money studying and testing it. They also spend a lot of money on advertising. In exchange for that initial investment, the US government allows drug companies to have a “patent” on their new medicines. Patents give drug companies the right to be the only ones to sell a medicine for the first several years it is available. Later, when the patent runs out, other companies can come out with generic copies of the medicine.

Makers of generic medicines can charge less, because they don’t have to pay for developing or advertising the medicines. Still, a generic medicine can only be made and sold in the US after the Food and Drug Administration (FDA) has carefully tested and approved the generic version. Once the FDA tests and approves a generic medicine and the place where it is made, several companies can start making generic copies. At that point, the cost goes down even further, thanks to competition.

Are generic drugs as safe? — YES. FDA-approved generic medicines meet all of the same requirements for quality, strength, purity, and shelf life as brand-name medicines. Generic manufacturing plants in the US are subject to the same inspections and the same rigid testing as brand manufacturers.

For more information about the safety of generic medicines, see the resources section. (See 'FDA information for consumers' below.)

Do generic drugs work as well as brand-name drugs? — In almost all cases, yes. With very few exceptions, generic medicines can be substituted for the brand-name version and will work just as well. Each FDA-approved generic equivalent drug has been carefully tested and shown to be equivalent to the brand-name version [5-7].

Sometimes switching from a brand to a generic or switching between different generic copies could cause problems for a small number of people with certain conditions. That could include people who have difficult-to-treat seizures or thyroid problems, or who take medicines to stop organ rejection after a transplant.

How do I find out if I can switch to a generic? — First, ask your doctor or pharmacist if any of the medicines you take are available as generics. Not all medicines come as generics. (You can check if a brand-name medicine is sold as a generic at this website: www.accessdata.fda.gov/scripts/cder/ob/docs/querytn.cfm.) But even if the medicine you take does not come in a generic form, there might be other medicines that can properly treat your condition that do come in a generic form.

If you are interested in switching to a generic, the important thing is to work with your doctor and to make changes only with your doctor’s approval. Generics are a great cost-saving option, but any time you switch medicines, you have to do it carefully.

Will I save with generic medicines even if I have insurance? — YES. You can save by using generic medicines even if you have prescription drug coverage or a Medicare Part D prescription plan.

Nearly all insurance plans have lower co-pays for generic medicines than they do for brand-name medicines. The co-pay is the amount YOU pay out of pocket each time you fill a prescription when you have prescription drug coverage. Plus, many insurance companies require less paperwork to cover generic medicines, so you can often get generic medicines faster than brand-name ones.

But lower co-pays are not the only reason to switch to generics when you have insurance. Many insurances and Medicare Part D plans have a set limit on how much money they will spend on your medicines every year. If you go over that limit, you have to start paying for your medicines on your own. But, if your medicines cost less, you may never reach that limit all year, or at least reach it more slowly. If you reach the coverage limit and have to pay on your own, it will cost you less with generics than with brands. (See 'What if I am eligible for Medicare Part D prescription coverage?' below.)

Some insurance companies also require you to spend a certain amount of your own money on medicines first, before they will start paying for them. The amount you pay first is called a deductible. You can make the most of that deductible by buying generics, if they are appropriate.

What about my non-prescription medicines? — Generic non-prescription (also called “over-the-counter,” or OTC) medicines are also safe and effective and must be approved by the FDA.

Sometimes prescription medicines are sold as non-prescription versions, usually at a lower strength. You should not use those instead of medicines you were prescribed without checking with your doctor.

ASK ABOUT SPLITTING PILLS

If you have NO prescription drug coverage or can spend only a certain amount on prescriptions each year, splitting pills can lower your cost on many commonly used medicines. This is because many prescription medicines cost the same no matter what strength the pill is. As a result, it is sometimes possible to get a prescription for double the strength you need and then to cut the pills in half. That way, you end up getting your medicine at about half the cost [8].

Take the cholesterol-lowering medicine Crestor, for example. It is not sold as a generic, so it is called “brand only.” A 30-day supply costs about $155 retail if you have no insurance.

If your doctor prescribed a typical dose of 10 milligrams a day for you, you could ask your doctor to change the prescription to the 20 milligram Crestor tablet with instructions to take half a pill a day. Then you could cut the pills in half and have enough doses for 60 days instead of 30. Your cost would then be about $78 for a month, saving you $940 a year on one medicine alone. Plus, you would get to stay on the brand-name medicine your doctor prescribed.

The cost savings for splitting pills is usually highest for brand-only medicines, like Crestor. But you can also save money by splitting generic medicines. For example, the commonly used cholesterol-lowering medicine simvastatin (brand name: Zocor) is available as a generic. A typical dose is 20 milligrams a day, you can get 40 milligram tablets and take half a pill a day to get your regular dose. This will reduce your cost, even with no insurance coverage, from about $28 a month to $14 a month.

If you DO have full prescription coverage, splitting pills is NOT likely to save you money on your usual co-pay.

Which pills are safe to split? — Many pills, including those used to treat high cholesterol, depression, high blood pressure, and diabetes, can be safely split in half by someone with good vision and good use of his or her hands. But it is NOT safe to split ALL medicines. If you split the wrong type of medicine or do it incorrectly, you might get too much medicine too quickly or too little medicine.

Flat, round, or oblong pills, and those that have a line down the center for breaking, are easy to split. Medicines that come in capsules or in pills that are designed to release medicines slowly should NOT be split.

If you want to try pill splitting, FIRST ask your doctor or pharmacist if it’s a good idea. Pill splitting can work only if the pills you take can be safely split and come in a strength that is double the dose you need.

What is the right way to split a pill? — Always use a pill splitter to split pills. Have your pharmacist show you how to use a pill splitter. A pill splitter is a small, inexpensive plastic device that holds the pill in place and safely cuts it with a small blade (figure 1).

NEVER try to split a pill without a pill splitter. Never use a knife, which can smash your pills, and do not cut more than one or two pills at a time, as split pills can turn to powder if you shake them or store them.

If you do end up splitting pills, ALWAYS review the new pill strength and new instructions with your doctor, nurse, or pharmacist to make sure you are getting the right amount of medicine.

SHOP AROUND, BUY IN BULK

Another way to cut the costs of your medicines is to shop around. Find out which pharmacies or stores have the best price. Pharmacies do not all charge the same prices for the same medicines. Plus, many stores and pharmacies offer further discounts for buying in bulk — 100 pills or more at once. If you know you will be taking a medicine for a while, buying in bulk quantity can mean added savings.

BJ’s, Costco, Sam’s Club, Target, Wal-Mart, and other chain and “big” retail stores often have good deals on hundreds of generic medicines used to treat common medical conditions. Their prices are often as low as $4 for one month and $10 for three months.

You can check to see if the medicines you take are available at these ultra-low prices by asking for a brochure at the pharmacy in the store or by going online. You can find lists of discounted generic medicines for each store by entering the store’s name and the words “prescription program” into Google or another search engine. If the medicine you take is not on the list of low-cost generics at the “big” stores, print the list and bring it to your doctor at your next appointment. Then ask your doctor if your condition can be treated properly with a medicine that is on the low-cost list. This can save you thousands of dollars a year.

It is just as important to price shop for generic medicines as it is for brand medicines. Consumer Reports magazine did a price survey for generic Plavix (called clopidogrel), a medicine commonly used by patients who have had angioplasty or heart stents put in. The magazine found retail prices for a 30-day supply that varied from less than $15 at Costco pharmacies to $175 or more at other pharmacies, such as CVS [9]. Bottom line, it pays to shop around.

It is also worth checking and comparing prices at your local pharmacy, not just at the big stores. Some pharmacies will “match” the best price you find elsewhere in the area, if you ask them. To make shopping around easier, you can usually get a price from a pharmacy over the telephone.

MAKE THE MOST OF YOUR INSURANCE

If you have insurance, there are lots of things you can do to get the most out of your coverage. First, take the time to learn about your prescription drug coverage so that you can avoid expensive surprises. If you are eligible for Medicare Part D prescription coverage, there are ways to save money with that coverage, too. (See 'What if I am eligible for Medicare Part D prescription coverage?' below.)

If you have a choice between different prescription plans, get the list of medicines that each of the plans covers (called the “formulary”) and the different co-pay levels (“tiers”). Most insurance providers have a three-tier system that works like this:

• Tier 1 usually has the least expensive co-pay and includes mostly generic medicines.
• Tier 2 has a higher co-pay than Tier 1 and includes “preferred brand-name medicines.” These are brand-name medicines that the insurance provider has approved because they are proven to work and be cost effective.
• Tier 3 has the highest co-pay and includes “non-preferred” or non-formulary brand-name medicines that — according to the insurance provider — can usually be replaced with Tier 1 or Tier 2 medicines without any problems.

After you get the list of medicines that are covered by your insurance, check if any of the medicines you take are not covered or covered only with a high co-pay or in a limited way. For each of those medicines, ask your insurance company which covered medicines could work for you instead. Then give that information to your doctor.

Bring the list of covered medicines and their cost each time you visit a doctor. That way, if you need a new medicine, your doctor can prescribe one that is covered by your insurance at the lower Tier 1 or Tier 2 co-pay. If any of your current medicines are not on the Tier 1 or Tier 2 list or are expensive, ask your doctor if any of the medicines on the list can replace them.

Should I use the mail-order option? — If you have prescription drug coverage, most plans offer a mail-order option. This option will save you money on medicines you take for three months or longer. Mail-order is a good idea only after you know for sure that you will be taking a given medicine at a specific dose for at least three months. If you are still changing doses or are not sure if a medicine is going to work for you, you should not buy a three-month supply. If you do and you end up switching to a different medicine or a different dose, you might waste some of the medicine you got.

The mail-order pharmacies associated with state-approved prescription drug plans are usually large, reliable, licensed pharmacies that you can use with confidence. Even though they may not be located in your home state, they are licensed to dispense medicines in your state.

The mail-order option with prescription drug coverage usually has a discounted co-pay for a 90-day supply of generic medicines and preferred brand medicines. To use this benefit of your insurance, you will need to register for the mail-order option for your plan. You will also need to ask your doctor to write you prescriptions that cover a 90-day supply with each refill. You will need to send the mail-order pharmacy the original prescriptions with a completed form that they provide, or you can have your doctor fax the prescriptions with your form to the mail-order pharmacy. If you decide on the faxing method, it’s possible the doctor will have to write your prescriptions on a special fax form provided by the mail-order pharmacy.

What if I am eligible for Medicare Part D prescription coverage? — If you are eligible for Medicare, you can also enroll in a Medicare Part D prescription plan. There can be as many as 50 different Medicare Part D plans to choose from in your state, and each plan can offer a number of options that can be confusing.

A typical Medicare Part D plan costs from about $27 a month to more than $100 a month, depending on the specific coverage provided. The plans vary by many important details, including:

• How much you have to pay up front before the plan starts paying (called the deductible)
• The list of covered drugs (called the formulary)
• The co-pay amounts for generic and preferred brand drugs (called tiers)
• Whether there is any drug coverage after you exhaust the resources Medicare Part D is willing to spend on you for routine medicines (often called the “coverage gap” or “donut hole”)

It takes time to compare the different plans and their options, and it can be tough to decide which Medicare Part D plan is best for your needs. Fortunately, reliable help, even one-on-one personal help, is available. We recommend getting help from the government and non-profit sources listed in the resources section below for Medicare Part D. (See 'Resources' below.)

We do NOT recommend using a private insurance company’s Web site, television ad, or mail ad to select a Medicare Part D plan.

MAKE SURE YOU NEED ALL THE MEDICINES YOU ARE ON

Some patients are prescribed more medicines than they really need. This seems to happen more often to older adults with multiple medical problems and to people of any age who see different types of doctors for different conditions.

In some cases, two different doctors prescribe two or more medicines that do the same thing. To avoid this problem, bring a list of all the medicines you take each time you visit any doctor. On your list, include the dose you use for each medicine, why you use it, how you take it, and the name and type of doctor who prescribed it. An example of such a list can be found at www.fda.gov/Drugs/ResourcesForYou/ucm079489.htm.

Ask all of your doctors to review your medicine list at each visit to make sure the list is up to date and has no errors. For example, your doctors should make sure the list does not include any incorrect doses or any medicines you should have stopped taking. Also check with your doctor that every medicine on your list is still needed and that you are taking it the right way.

GET HELP PAYING FOR THE MEDICINES YOU NEED

If you already looked into switching to generic medicines, splitting pills, and cutting costs in other ways, but you still can’t afford your medicines, you might be able to get help another way. There are state and federal programs that help people pay for their medicines. Plus, there are assistance programs sponsored by non-profit organizations and by drug companies themselves. Whether you can get help from these programs will depend on things such as your income and how many people are in your family. Ask your doctor if these programs are available to you. You can also find information about these programs in the resources section of this article. (See 'Resources' below.)

If you are cared for at a hospital or in a large medical practice, there should be a social worker or a pharmacist there who can help you find programs that might be able to help you.

BEWARE OF FOREIGN OR INTERNET-ONLY PHARMACIES

Pharmacies based in other countries and ones that exist only online sometimes offer what sound like really good deals. But be careful. Stay away from any pharmacy that offers to sell you prescription medicines without a prescription from a doctor who has actually seen you. The FDA has found that some Internet and foreign pharmacies are not properly licensed and inspected. Plus, they may sell you medicines that are not right for you or that are expired or even fake [10-12]. You can find out if an internet pharmacy is licensed in US by checking the FDA website called “Know Your Online Pharmacy” listed in the resources section in this article. (See 'FDA information for consumers' below.)

Pharmacies in Canada might be reliable, but the FDA has no oversight of their activities, so the agency cannot endorse the use of Canadian pharmacies.

There is no need to risk using an Internet-only or foreign pharmacy just to get mail service. There are better ways to shop for low prices and order refills privately and conveniently online. The mail order choice for your prescription plan usually has an online order program. Also, most big chain stores and many local pharmacies now offer free mail-order service and let you order by phone or online at no extra charge. It is much safer to order online from a pharmacy or store that you know and could physically visit if it was necessary.

To order prescriptions online from a big store or local pharmacy, ask the pharmacy staff how much your prescriptions will cost if your order that way. Then follow the instructions on their Web site.

RESOURCES

Help with understanding and choosing a Medicare Part D plan — These Web sites are only for people on Medicare.

Medicare — This is the official government Web site that lists the different drug plans Medicare offers. Here you can compare the plans offered in your state and view each plan’s formulary (list of covered drugs).

• General site: www.medicare.gov
• Site with information on state help with drug payment (how to contact each program, who is eligible, and other details you should know): https://www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx
• Phone: 1-800-MEDICARE (1-800-633-4227)

Medicare Rights Center — This is an independent non-profit consumer advocacy group that helps people navigate the Medicare system. The group offers a hotline with counselors who can answer questions and help you make the most out of your Medicare coverage.

• Web site: www.medicarerights.org
• Phone: 1-800-333-4114

Social Security Extra Help Program — Only for people with Medicare, this official government site has information about the Extra Help program. The Extra Help program helps people pay for the costs — monthly premiums, annual deductibles, and prescription co-payments — related to a Medicare prescription drug plan.

• Web site: www.ssa.gov/prescriptionhelp
• Site with information about applying to the Extra Help program: www.ssa.gov/pubs/10525.html

SHIP: State Health Insurance Assistance Program — SHIP is a national program that offers counseling and help to people with Medicare and their families. This site can help you find a counselor in your area who will meet with you one on one and talk to you about your Medicare options.

• Web site: www.shiptalk.org

Help paying for your medicine — These Web sites provide information about different programs to help you pay for medicine.

Benefits Checkup (National Council on Aging) — This site gives people lists of services and programs for which they can apply. The lists include programs to help pay for medicines, but also programs that don’t have to do with healthcare directly. For example, this site has information on finding housing, getting food stamps, and finding elder care. You can search for all types of programs at once, or target your search to find a specific kind of service.

• Web site: www.benefitscheckup.org
• Phone: 1-800-677-1116

Needymeds — This is an independent non-profit organization that provides information about patient assistance from drug companies and the government. The site also offers people a discount card that they can use on prescriptions if they have no insurance or choose not to use their insurance. This card is especially useful in paying for medicines after you reach the Medicare “donut hole,” and Medicare is no longer paying for your prescriptions.

• General site: www.needymeds.org
• Site with state health insurance assistance program (SHIP) information: www.needymeds.org/indices/ship.htm

Partnership for Prescription Assistance — This program is run by drug companies and their trade group. It is only for people who do not have prescription drug coverage. The site helps people find programs that will get them medicines for free or for a reduced cost.

• Web site: www.pparx.org
• Phone: 1-888-4PPA-NOW (1-888-477-2669)

Rx Assist — This site lets you enter the name of a medicine or the name of a drug company to find programs that can help you get that medicine or medicines made by that company at a reduced cost. In many cases, the online applications for those programs are included.

• Web site: www.rxassist.org/patients
• Phone: 1-401-729-3284

Rx Outreach — This site offers medicines and diabetic treatment supplies at a reduced cost to people who make less than a certain amount of money each year.

• Web site: www.rxoutreach.org
• Phone: 1-800-769-3880

Learn more — These Web sites provide extra information and tips to help you make smart choices and protect your rights when looking for healthcare.

FDA information for consumers

• Government sites with information about safety and quality of generic drugs:

• “Generic Drugs: Same Medicine, Lower Cost”: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm340343.htm?source=govdelivery
• “Generic Drugs: Questions and Answers”: www.fda.gov/Drugs/ResourcesForYou/Consumers/QuestionsAnswers/ucm100100.htm

• Government sites with information about buying drugs online safely:

• “Know your Online Pharmacy”: http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/BuyingMedicinesOvertheInternet/BeSafeRxKnowYourOnlinePharmacy/default.htm
• “Buying Prescription Medicine Online: A Consumer Safety Guide”
  http://www.fda.gov/Drugs/ResourcesForYou/ucm080588.htm

• Government sites with information about the risks of foreign and Internet pharmacies:  

• “The Possible Dangers of Buying Medicines Over the Internet”
  http://www.fda.gov/forconsumers/consumerupdates/ucm048396.htm

• “Buying Medicine from Outside the United States”
  www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/buyingmedicinefromoutsidetheunitedstates/default.htm

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our Web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

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Patient information: Medicines for atrial fibrillation (The Basics)
Patient information: Latest medicines to prevent blood clots (The Basics)
Patient information: Medicines for chronic kidney disease (The Basics)
Patient information: Disease modifying antirheumatic drugs (DMARDs) (The Basics)
Patient information: Liver transplant (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

This topic currently has no corresponding Beyond the Basics content.

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.