Can’t afford your prescription? You have options.

Last year in January, Cole Schmidtknecht of Appleton arrived at a Walgreens pharmacy counter to find that his daily Advair Diskus inhaler was no longer covered by his insurance. 

That meant the price he would have to cover had risen by more than 700 percent. He was unable to afford it, and left empty handed. Five days later, he died of a fatal asthma attack. 

Now, his family is suing Walgreens for not offering Schmidtknecht available workarounds or alternative medications. They’re also suing Pharmacy Benefit Manager OptumRx for failing to notify him of the cost increase in advance. 

If Schmidtknecht had known that he had other options, he might be alive today. But according to Bobby Peterson, founder and public interest attorney at ABC for Health, the health care system isn’t designed to be navigable for the average person.

“You need a level of expertise,” Peterson told WPR’s “Wisconsin Today.” “You need to know what exactly the details of your plan are, how to get them and how to stand your ground when people say ‘No.’”

Dan Weissmann, creator and host of the podcast “An Arm And a Leg,” agreed.

“Thinking about what your health care costs you is like the worst possible game of Choose Your Own Adventure, because there’s a million choices, and everything is particular to you,” Weissmann told “Wisconsin Today.”

Weissmann and Peterson explained what options the average person might have when encountering surprisingly high prices at the pharmacy counter.

Take a deep breath

Being surprised by the cost of your prescription at the pharmacy counter can be a stressful experience.

“You’re at the pharmacy desk, there’s five or six other people in line behind you and it just becomes a pressure-filled situation,” Peterson said. 

Many people who encounter obstacles with their insurance are going through additional stressors at the same time, like being sick, dealing with medical debt or changing jobs.

Weissmann advised people to avoid the impulse to panic and, instead, take a step back.

“The first thing to do is take a breath — this is really important. Let’s ask some questions,” he said.

Ask the pharmacist about alternatives

The first person you should direct your questions to is the pharmacist. That may not be the same person who dispenses your prescription at the counter, so you may need to ask to speak with them.

“Normally, you [can] expect a pharmacist to identify whether this is a covered drug,” Peterson said. “And if it’s not covered, make sure that alternatives are identified.”

If the pharmacist doesn’t offer other options, Weissmann suggested asking specific questions.

“Is there another medicine like this that I could take, and can you give it to me?” Weissmann said. “Is there a generic [version] of this?”

If there is a less expensive alternative, your pharmacist may be able to make a substitution on the spot. Wisconsin law states that pharmacists can choose to dispense a generic version of a medication if a patient’s doctor doesn’t specify otherwise. If you’re not sure whether an alternative will be right for you, Weissmann recommends calling your doctor to check.

Try a coupon

If the pharmacist can’t dispense an alternative, there’a another question you can ask.

“Is there a coupon for this? Can you check and see if the maker of this drug offers a coupon that would lower the price for me?” Weissmann said. 

Alternatively, Weissmann suggested stepping away from the counter and searching the internet for a coupon yourself. If you don’t find anything, a website like GoodRx might yield results.

“GoodRx is a guide for [prescription] offers and will tell you what a medicine will cost you at different pharmacies, because that can vary too,” Weissmann said.

Involve in your doctor

If you can’t find coupons or less expensive alternatives, your doctor may be able to help you get the name brand drug covered through a process called “prior authorization.”

“[That’s] if they can certify to the Pharmacy Benefit Manager that you need this version of the drug,” Weissmann said. 

But your Pharmacy Benefit Manager — the intermediary that negotiates prices with drug manufacturers and pharmacies for your insurer— may require you to jump through hoops first.

“Frequently, they’ll say, ‘Put them on the generic first and if it fails, then let us know, and we’ll think about it,’” Weissmann said. “They call it ‘step therapy.’”

If you change insurance, your new Pharmacy Benefit Manager may require you to go through “step therapy” again.

Check the formulary

The formulary is a comprehensive list compiled by your insurer of all kinds of medicines you might be prescribed, categorized by “tiers” that correspond with how much each one is likely to cost you at the pharmacy.

You can usually find your insurance’s formulary online. By searching the formulary for your prescriptions, you can find out whether they’re covered, how much they might cost and whether you will be able to afford them.

“Here we are rewinding the clock back to months before you wind up the pharmacy counter. This is how you would know in advance,” Weissmann said. “Then you have the lead time to go to your doctor and say, ‘What are my options? Is the generic just as good for me?’”

Formularies can change from year to year, so it’s a good idea to check for changes at the start of your insurance year, or whenever you change plans, said Weissmann. 

Look to additional resources

Since each person’s health insurance plan is different, it can be difficult to know what your rights are according to your contract.

“People don’t know the rules of their health plan. They don’t have it in their hands when they’re going up to the pharmacy desk or they’re trying to get services. You need a level of expertise,” Peterson said. 

If you’re running into a wall when dealing with insurance and you’re not sure where to go, you may have access to free resources and advising services in your area or online. 

Here are some places to look:

• Wiscovered.com
• Covering Wisconsin
• State Health Insurance Assistance Program (SHIP)
• Your local Aging and Disability Resource Center 
• Your local Veterans Service Office
• ABC for Health

Weissmann said you can also try asking for help from those around you, and offering to help others when you can.

“I think that the more of us get informed, the better off we’ll be, and that we can learn both to help ourselves and to help each other,” Weissmann said. “Now that I know this stuff, I can tell you about it. Buy me a beer tomorrow, I’m going to take an hour and help.”