Episode 4 | Behind the Pharmacy Counter

Pharmacists offer an insiders' look at the process and costs involved in filling your prescriptions for thyroid hormone replacement drugs--and how to save.





TRANSCRIPT

“You have a choice. There's always a choice. And I think that a lot of the people involved in our world make it seem as if there's only one choice: your copay or bust. And that's not the case. If it's not covered by your insurance, or it seems unreasonably high, there's always other options.”

~ Dr. Jessica Nouhavandi, Co-founder of Honeybee Health

“Do a little homework, but also ask your pharmacist. You don't necessarily want to be pushed in a direction that maybe isn't therapeutically good for you, but if you have a pharmacist that you trust. There’s a lot of interesting things that pharmacists can do to help you save money, that will keep you on the right therapeutic track.”

~ Chris DiLascia, President of Transition Pharmacy Services



MARY SHOMON: Do you want to finally live and feel well with a thyroid condition? Then I want to welcome you to the Thyroid Deep Dive podcast. I’m your host Mary Shomon. It’s time to dive in!


Whether you are newly diagnosed with hypothyroidism, or you’re a long-time thyroid patient like me, one of the most important parts of our treatment is filling the prescription for our thyroid hormone medication. And that’s when the fun really starts, right?


Well, for many of you, every time you fill a thyroid prescription it’s a roll of the dice. Will you get the exact medication your doctor prescribed? Will the pharmacy say it’s out of stock, but gee, for some mysterious reason, it’s not out of stock at the pharmacy across the street? Will your pharmacist substitute a different brand or give you a generic without even telling you? Will your insurance even cover it? And how much will it cost? Will the prescription that cost you $15 last month run you $40 this month -- and $70 next month? And, why is your friend paying half the price for the same prescription drug?


In this episode, we will be hearing from two experienced pharmacists who have worked in retail, online and specialty pharmacies for several decades. Dr. Jessica Nouhavandi is cofounder of online mail-order pharmacy Honeybee Health.


Chris DiLascia is president of Transition Pharmacy Services, also known as TPS, a specialty pharmacy.


In this episode, Dr. Jessica and Chris take us “behind the counter,” to explain what’s really going on at pharmacies when we get our thyroid prescriptions filled.


Here’s a statistic that may shock you: Research shows that half of all patients are overpaying for their thyroid medication! Are you one of them? You have a 50-50 chance. There’s NO reason to be overpaying! And the pharmacists and I will help, highlighting various ways you can save money on your thyroid prescriptions…in some cases, as much as hundreds of dollars a year!

So, this is Mary Shomon, and let’s dive in to “Behind the Pharmacy Counter,” episode 4 of the Thyroid Deep Dive podcast.


The Regular Pharmacy Process


MARY SHOMON: Let’s start by reviewing the typical steps involved in getting a prescription filled. You consult with a health care provider, and they prescribe a medication. The prescription is transmitted electronically, called in by phone, or you get a paper prescription. You can then get your prescription filled by a mail order pharmacy, which some health insurers and HMOs offer, or in-person from a pharmacy, as the majority of people do. TPS’s Chris DiLascia walks us through the process.


CHRIS DILASCIA: The normal process is, as you’re well aware, that a patient goes to a physician's office, they're diagnosed, they receive a prescription for medication.

From my clinical perspective as a pharmacist, the decision has been made between the patient and the physician as to best therapy for that patient, given their situation and the course of their disease.


So that patient leaves the office with a prescription. They go down to their corner drugstore, or sometimes they don't. Depending on the patient and medication and the situation, some prescriptions get filled, some do not simply because the patients don't ever fill them. We find that out of every 100 prescriptions that are written, generally speaking, about 50% of them never make it to the pharmacy. And of those that do -- because some are called in by the office directly to the pharmacy -- about another half of those get filled.


So you're usually typically in the 30 to 40% range in terms of the prescriptions that actually get filled...probably a little bit higher for thyroid, because it is a chronic condition and it is something that patients have symptomatology. And that generally tends to drive patient behavior better than let's say, high blood pressure, for example.


So they'll go to the pharmacy with the prescription and if it's a brand name product, it'll be written with the brand name in many cases by the physician. The states will, however, have generic substitution laws that mandate that pharmacies fill a prescription with a generic, unless the patient requests otherwise, but that's only for products that are what they call it AB rated.


In other words, the government has decided that they're legitimately equivalent to each other, from a clinical standpoint. When you're talking about thyroid medications, medications that have what they call a narrow therapeutic index, it becomes a little bit more concerning because patients are titrated to a specific blood level. And any variation in that blood level can cause issues. So, a couple things happen.


Patient goes to the pharmacy; they've got the brand name prescription. If it happens to be for a brand name thyroid medication that has a generic equivalent, it will automatically be substituted with the generic. If it's written for Tirosint, which at this point does not have an AB rated generic equivalent, the pharmacist will go to fill up with Tirosint. And one of two things can happen. One is the payer— the insurance company that the patient’s getting their medication covered by – may have what's called a prior authorization in place, meaning that the doctor needs to make a phone call, to the health plan. Or sometimes, there's a more automated process using technology, but the physician will have to validate that that prescription is necessary for that patient to the health plan so that the health plan will agree to pay for it. This creates a hiccup in the process because now the patient is standing in the pharmacy and the pharmacist is telling them, “You need to call your doctor,” because most busy pharmacies won't do that for you.


So the patient has to leave and then go and call their doctor. Then the doctor has to either. go through the process of getting the prior authorization at the health plan or, in some cases, write for a different medication. And at that point, the patient has to go back to the pharmacy, get the prescription filled.


What happens on occasion is what's called therapeutic interchange and that's where the pharmacist, within the laws of the particular state and state board, is authorized to offer the patient a different brand that has a generic substitute that's deemed to be therapeutically equivalent, or they may call the doctor and ask the doctor, “is it okay if I switch to this other product.” Nine times out of 10, they're doing that predominantly because, either there's a prior authorization in place or because when the pharmacist processes the prescription for a branded product such as Tirosint, the cost could be significantly more than the cost for a generic medication. So, the pharmacist, trying to be a good citizen, will try to get that patient on the less expensive medication, knowing then we're saving them some money and knowing that generally there's an equivalency there, or that the doctor is authorized that change to a product that has a generic equivalent and therefore saving the patient the additional cost. Those are the kinds of things that patients run into at the pharmacy, whether they have to leave and come back with the doctor's authorization, whether they have to pay an unusually high copay, or whether the product is even covered at all by their health plan.


In some cases, the health plans have already made a decision that they're not going to cover this brand. They're only going to cover this other brand, and the generic of this other brand, because they've either gotten significant rebates from a pharmaceutical manufacturer, or, in their financial analysis, the medications are equivalent enough and they're trying to save money for the ultimate payer, which in most cases is the employer or the government. That sort of gives you a sense of what happens on the pharmacy side.


Pharmacy Substitution


MARY SHOMON: As Chris explained, there’s often a push to give patients cheaper brands or generic drugs, because they’re less costly for patients, and more profitable for pharmacies. That means that pharmacy substitution is very common. Whether it’s your pharmacy substituting a lower-priced brand than the one you were prescribed, or they’re giving you a generic instead of the brand that was prescribed, it can be a challenge to get the specific thyroid drug you need. I asked Honeybee’s Dr. Jessica Nouhavandi what patients can do about substitution.


MARY SHOMON: What about the situation where patients are prescribed a brand name drug? Let's say they're prescribed a brand name in the levothyroxine category. And they're prescribed that because they've taken it in the past. They've done well with it. The excipients or ingredients in it don't have sensitivity problems for them. And they've been able to get good control of their hypothyroidism on that medication.


But when they go to the pharmacy, they are constantly being told, “Well, we're going to give you the generic” or “we're going to substitute something else.” And then they're getting a medication that may not be the right excipient mix. It may not be the same potency within the reference range of potency that the FDA sets for this medication, and patients are dealing with a run-around situation. What can they do about that situation?


DR. JESSICA NOUHAVANDI: Well, the number one thing is, if you have been taking a medication that works for you, you first have to be your own patient advocate and be very vocal when you're at the pharmacy about what works for you. And actually, you can deny getting the generic, if that's what it is. You can say, “I only want the brand name,” and they have to fill that. And there's something on the prescription called a “DAW code,” and it's a dispense as written code and oftentimes doctors will check it off. And you have to dispense it as written because “this is what my patient needs.” And then there's one where there's a DAW code where the patient says, “this is what I have to have, because I know I've been taking it for a while and this is what works for me.” So, the number one thing is if you go to drop off a prescription or your doctor is sending an electronic prescription to a pharmacy, you need to make sure that there's some sort of DAW or you need to communicate to the pharmacy, that this is exactly what you want.


If it's not covered by your insurance, or it seems unreasonably high, there's always other options. This is where we come in. We have a lot of patients that come to us at Honeybee that just want to search pricing and see what it would be out of pocket. And to be honest with you, Mary, a lot of times it's cheaper to pay out of pocket than it is to use insurance. So, number one, you have to be your own patient advocate. And if it's been working for you and you feel good, you deserve to feel better. That's what you should stick to.


Generic Levothyroxine


MARY SHOMON: So, let’s talk about generic levothyroxine, the most commonly written prescription for hypothyroidism. Levothyroxine is the synthetic version of the T4 hormone. There’s nothing wrong with generic levothyroxine tablets if they work for you to treat your hypothyroidism. But there are some challenges that I discussed with the pharmacists, starting with Chris:


CHRIS DILASCIA: With thyroid medication it’s particularly important, for a couple of reasons. One is if the patient does go on a generic medication, a pharmacy might purchase one brand of generic medication this month, but next month might find a better price on a different brand of generic medication and go to a different brand. If the patient's stabilized on that brand, and now they go to a different brand, the patient may be getting a little bit more medication than they should. Or the contrary, the patient might go from a higher level to a lower level and get a little less medication, which most pharmacists are pretty good at understanding that there are medications where that's the issue, and that's certainly true with thyroid medication. In many cases they'll stick with one generic, but there's always that possibility, for a few dollars here and there, that a patient may end up on a different generic, and it might cause some therapeutic issues.


MARY SHOMON: Honeybee’s Dr. Jessica shares her thoughts on generic levothyroxine drugs.

When it comes to hypothyroidism, the vast majority of people with an underactive thyroid do take synthetic T4, levothyroxine. People would recognize the brand names, Synthroid Levoxyl, Unithroid. A smaller number of people are on Tirosint liquid or Tirosint capsules. But this is the vast majority. Only a smaller percentage of patients are taking natural desiccated thyroid drugs, like Armour or Nature-throid, or WP thyroid. So, we have this large number of millions of people a year taking synthetic T4, levothyroxine drugs, and many of them are taking generics. And we're also finding a lot of them, in terms of studies and things are not well controlled. Their numbers are all over the place in terms of their thyroid levels. And I’m wondering if you can tell us a little bit about what is going on.


DR. JESSICA NOUHAVANDI: When you go to a traditional pharmacy, they give you whatever generic they have in stock based on PBM and the reimbursement and what's on formulary.

What many people don't know is that even though they all have the same active ingredients, the inactive ingredients, which sometimes we call fillers, dye, and things like that, can vary from manufacturer to manufacturer. There’re no two manufacturers that have the exact same formula. And so, you see variants.


And that's why we do recommend sticking to the manufacturer that you've been on that works for you. And you know the tablet shape, the color, the marking, and everything like that.

Consistency is really, really important. And switching from generic manufacturer to generic manufacturer can often be detrimental to your therapy. So, there are certain disease states where this matters more and thyroid’s definitely one of them.


Your Copay Price


MARY SHOMON: You may know exactly which brand or generic works best for you, but there’s another important question: How much will it cost? It’s kind of a trick question, actually. Because it depends on how you’re paying, and where you’re getting your prescription filled.

The majority of Americans have health insurance, so let’s start with the co-pay price. That’s the price you pay at the pharmacy for a particular medication when you put it through your health insurance coverage.


Each health plan assigns a drug to a particular copay tier or level, based on a drug's list price and other factors. Inexpensive generics and cheaper brands are in the lower tiers with the lowest copays. Brand-name drugs, especially ones with higher prices, are in the higher copay tiers. In some cases, health plans may not cover a particular brand name drug at all.

Copays can range from nothing to around $10 to $15 for the Tier 1 drugs – usually the generics and cheaper brands, up to as much as 50 to $100 or more for Tier 3, 4 and Tier 5 drugs, typically the higher-priced brand names.


With thyroid drugs, you’ll find they are assigned to various tiers depending on your health plan. Some health plans don’t cover Tirosint, the gel cap and liquid form of levothyroxine, at all or put it in the highest tier. And many plans don’t cover natural desiccated thyroid drugs, or if they do, they put them at higher tier copay levels.


Chris DiLascia explains more about insurance copays.


CHRIS DILASCIA: In most cases, if they're paying the $20, $25 $35, up to in some cases $50, depending on the health plan, those are the copays that are associated with a specific tier level. that pharmaceuticals are placed in underneath the health plans. And those are usually driven by the pharmacy benefit managers, the PBMs as they're called, and the benefit designs that they designed for their employers.


So they'll have a generic level, which will be tier one, and it'll have a copay of $10, or, depending on the medication, could be zero. Then, if you go all the way up to the brand level, and if it's a brand that the health plan feels is expensive and that there's better alternatives from a financial standpoint, they may put it in tier three or tier four, or sometimes tier five. and they'll put a $50 copay on it. They may also put a prior authorization on that, where the patient has to get the doctor's permission.


Or they may have a situation where it's called a therapeutic ladder. You have to go on one medication first and fail before they'll allow you to go on the other medication. Those are all barriers that the benefit designs of health plans and PBMs put in play.


MARY SHOMON: Dr. Jessica gives some additional details on the copay situation.


DR. JESSICA NOUHAVANDI: There's a couple of reasons why people are paying so much at the counter when they do use their insurance. And one of the reasons is that the truth is that most people in our country are under-insured meaning they have high deductible health plans that have a high out of pocket amounts that they have to meet. And you have people sitting behind the desk, in offices run by PBMs, which are pharmacy benefit managers, who are the ones that are deciding what's on your formulary and what is it. And a formulary is a list of drugs, and it has tiers and it basically says what kind of drugs your insurance will cover and what they won't. And usually they tier it out, depending on the type of drugs. And oftentimes, brand name drugs aren't covered on people's formularies. And if they are, they're top tier, meaning the highest tier copay. A lot of times what we're seeing at a traditional pharmacy counter that accepts insurance is that either the copay’s too high or they're not covered and they have to go through a prior authorization phase, meaning the doctor has to call the insurance and say, “yes, this is what I want my patients to take.” And it often takes a lot of time for it to go through. And even then, the copay is still high if they do decide that they're going to cover it.


And so oftentimes pharmacies will carry generic manufacturers that provide them the greatest profit or reimbursement from the insurance company or PBM. And so, with brand name drugs, unfortunately, pharmacies often don't make any money at all. And so, they don't carry many of them, or they just lose out on a lot of patients for that.


So, that’s kind of what happens from a pharmacy side. Their hands are a little bit tied when it comes to what they can carry to continue to have a profitable business. But at the end of the day, traditional pharmacy that takes insurance is a business after all as well.


MARY SHOMON: Copays can also change, month to month, as Dr. Jessica explains.


DR. JESSICA NOUHAVANDI: One of the things that we keep seeing is the copays fluctuate, right? In a traditional pharmacy where they take insurance, we see the copays fluctuate from month to month. So oftentimes people who are on a fixed income are unable to predict what their costs of their medication will be.


MARY SHOMON: You may have heard about grocery chains and retailers and pharmacy chains who offer very low copays for selected generic drugs, including generic levothyroxine. But, as Chris DiLascia explains, there is a downside.


CHRIS DILASCIA: The $4 copays that you see out there are generally from places like Walmart, where they've decided that they're going to offer these medications to patients for a $4 cash price. And what drives that in many cases for these stores is getting the patient into the store, because they know if the patient buys their pharmaceuticals there for four bucks, they're going to spend another $13 to $50 there on other items while they're in store.

So they can offer that sort of as a loss leader. You have to make a determination as a patient, whether the trade-off on price is something that is worth it, from a clinical standpoint.


MARY SHOMON: So, as Chris explained, you may be able to pay only a few dollars a month for a generic levothyroxine. But, if you can’t specify the brand or generic that works best for you, your treatment may not be as effective.


Direct Enrollment Price


MARY SHOMON: A second category of drug prices are the “direct enrollment” prices. The three highest-priced thyroid hormone replacement drugs—Synthroid, Tirosint capsules, and Tirosint-SOL solution—have these “Direct” programs available. You fill your prescription with a designated mail order pharmacy that sources medication directly from the manufacturer, then the pharmacy sends it directly to you, bypassing wholesalers, pharmacy benefit managers, and other middlemen who add to the costs.


You’ll find links to these direct enrollment programs in the show notes and at the website.

These direct enrollment programs help you get the best possible insurance copay price, usually around $25 a prescription for Synthroid, Tirosint, or Tirosint-SOL. And, if you don’t have insurance, you have a high deductible, or your insurance won’t cover these brands, you can pay a low cash price. Tirosint, for example, is $50 a month, or $40 a month for a 3-month supply.


TPS is a designated pharmacy for the Tirosint Direct Program, and Chris DiLascia explains how it all works:


CHRIS DILASCIA: When a prescription comes to us, it's a different story. We get the prescription sent to us either by electronic prescribing, which is very common now, or through a fax from the physician's office. We will actually reach out to the patient, so, there's no gap there in terms of patients not going to their pharmacy. We're reaching out to them, calling them on the phone, to start that process for them.


We also have all the options in front of us. We can manage a prior authorization process for the patient. We can offer the patient the lowest possible price that's available to them, whether that's a cash price that the manufacturer is offering, a coupon we can apply that the manufacturer has put in place, or whether we can somehow find a way to get them the lowest possible copay.


So, they'll immediately be paying the lowest possible price. It's not being left up to the pharmacist to know whether or not there's a coupon available, or a cash price, which sometimes they don't know is available or if they don't know how to process the coupon, they run into problems that way.


We've got that process airtight. So, the patients are contacted, which gets our fill rates, on average, a lot closer to 80%, as opposed to the 35%, because we're reaching out to the patient. We're managing them through their insurance and coverage process so that they get the product covered or with possibly the best price available to them.


And then, once the patient okays the prescription to be filled, we send it to our pharmacy. They fill the prescription, they put it in an envelope or a box, and ship it to the patient. Usually that happens within 24 hours. We then send the prescription to the patient.


For thyroid medication, which is important. we use two-day FedEx to get the prescription to the patient. We can overnight it if we need to, but in most cases two-day FedEx is good enough. And then for refills, we can go to the US Postal Service, which is more cost-effective for everyone involved. And so, we're filling the prescription, it's a lot less of a hassle for the patient. They're guaranteed to get the best price possible for them. We have the medication in stock and the most important thing to me as a pharmacist is that the decision that the patient and the physician made in that office -- that this medication is the right medication for this patient -- we're honoring that relationship, that bond that was made there, and not trying to put the patient on a different medication, which may or may not be something that doctor would find, right for the patient, and making sure that they get that medication.


Other pharmacies are calling the patient back two or three times to get everything squared away. We've got the process down so that we're very efficient. And usually within a three to five-minute phone call, we can get all the information we need, and execute the patient section of things, which allows us to get our stuff out the door, right away. Our business model has been working directly with, with the manufacturers to try and improve access and adherence to medication, which ultimately benefits the healthcare system by improving outcomes, and that's been our main focus.


MARY SHOMON: That's a great overview of the process. So what I'm hearing you saying is that a specialty pharmacy like TPS, you are doing a lot of the groundwork and homework for the patients and the negotiation with the insurer and the doctor, and making sure, as you said, that the original prescription intention of the doctor is being honored for the patient, and that we're not adding in substitutions and things that may not be appropriate for this patient.


CHRIS DILASCIA: And in some cases, this physician has made that choice specifically because they would like the patient to get on a brand that they know isn't going to be substituted with possibly a generic that has different levels, which creates some follow-up that maybe didn't need to occur for the patient's physician. But also, that they're, getting to stable blood levels more quickly, which makes the patient feel better sooner.


With Tirosint, being a brand, the way it's absorbed in the body is really the difference between Tirosint and a lot of the other thyroid replacements out there, that patients get to steady stable blood levels a lot more quickly, which allows for a lot less titration. And they know that once their level is set, the medication they're taking will be consistent in terms of the amount of medication per tablet, and that as long as they're not doing anything on their end to disrupt it, then they're going to be stable over the long course.


Retail Cash Price


MARY SHOMON: When it comes to paying for your medications, as I mentioned, about half of all thyroid patients are overpaying. And one surprising reason is that your insurance copay may actually be more than the retail cash price – the amount you would pay without insurance, at a local or mail-order pharmacy. Unless you meet your deductible, it sometimes makes sense, then, to pay the cash price.


How can you find out the best prices? Your first step to save is to do your research. That means checking the manufacturer’s site to find copay coupons and discounts. You should also search at services like GoodRx and SingleCare to get an overview of different local prices. And, search using a service like Honeybee pharmacy, to get an idea of the lowest cash prices by mail order. Chris DiLascia explains the process he and his family follow.


CHRIS DILASCIA: I can give you my personal experience with my family. As a pharmacist, I know quite a bit. My wife is an accountant, so she knows a little bit less about pharmacy. But the reality is, whenever she gets a prescription for herself or for my daughter, I always say, "the first thing you need to do is go online and look for coupons or discounts." I suggest you go to the website for the company that manufactures the product. If it's a brand, if they have programs that are available to you, they'll be pretty easy to find all in one place there.


GoodRx is another great place, because most people nowadays – even though they might have insurance through an employer – are paying cash for their prescriptions because they're not hitting their deductible. The only time I've hit my deductible in the last 10 years is when my wife and I both had a surgery, a procedure in the same year, with my kids' checkups and everything else, we, we still never hit the deductible and I'm paying cash for most of my scripts. So, at the end of the day, we look for the coupons and GoodRx is a place where, if you're paying cash, they have discounts available for that as well.


MARY SHOMON: Part of your research really should include a discount mail-order pharmacy. I’m a fan of Honeybee, because they are a pharmacy that operates only with retail cash prices – no insurance. They are the only pharmacy that lets you know in advance which excipients are included in different generic thyroid drugs, which eliminates the risk and guesswork for those thyroid patients taking generics. Best of all, they almost always have the lowest prices for many medications – not just thyroid, but other drugs that thyroid patients may be taking, like drugs for type 2 diabetes, and common drugs like antibiotics and antidepressants.


DR. JESSICA NOUHAVANDI: Our model is based on generic prescriptions. Nine out of 10 prescriptions dispensed in this country are generic, but often they're very inexpensive, but oftentimes patients never get to see that benefit of it being generic. They often have to pay the same price, those high copays.


And so we really started Honeybee for, we have over 6,000 generic drugs listed on our site, but the idea that look: Generic prescriptions are actually very inexpensive and you should have access to that information and that pricing, before you even go to the pharmacy or before you see your doctor.


And this is one of the reasons why we started Honeybee, which is a direct pay model for patients, because we knew that outside of everybody else, having a hand in getting involved in pricing medication and determining what you can and can't have. The actual cost of the medication isn’t all that expensive to begin with, especially generic.


We created a model where, you can just simply search your medication and see what the price is without having multiple people got involved.


And we're giving patients an opportunity to be able to see the non-active ingredients that they care about, and to be able to look at the manufacturer and see the reputation of the manufacturer. How long have they been manufacturing this drug? What's their reputation?


I think this is really important moving forward, especially for the thyroid community, because historically, we haven't been able to do that. Traditional pharmacy doesn't allow for consistency, and consistency of medication and treatment. And this is the first time where we're actually saying, “Look, we know this matters to patients, especially patients from this community,” and we're making an effort to cater to that. So, we're very excited. We think this is a huge step for the thyroid community to be able to have some consistency when it comes to their treatment and how they feel. Mary, you know how different it can be from manufacturer to manufacturer. And people rely on this to live and to be happy, healthy, and live a normal life. And they should have consistency when it comes to their choice of generic manufacturer.


There's no one size fits all here. Right? I think that your listeners and you as well understand this when it comes to thyroid. It's different for every single person. And you know, like a lot of my patients, they just know the color and the shape and they know roughly what it looks like. And so, you'll be able to also see the picture of the medication when you're on our site, so you can easily identify it. We help patients find the manufacturer that worked for them so that they can get it. It's going to be game changing for thyroid patients. So, we're really excited.


Getting Prescriptions from a Mail Order Pharmacy


MARY SHOMON: As you are hearing in this episode, some of the best prices for your medications are likely to be through a mail-order pharmacy. But what if you haven’t used a mail order pharmacy before? You may have questions about whether it’s safe and reliable. I discussed this with Dr. Jessica.


A question for you about mail order prescriptions, because some people have been doing it. They may have been familiar with it if they're in an HMO or their health insurance company might have mail order, but a lot of folks are still operating the old way. They go down to their local pharmacy, drop their prescription off, or the doctor transmits it over and they go pick it up at a local drugstore, the way we've been doing it for decades.


How is the mail order process different and how quickly can we get our medication back once we've put a prescription in, and is it safe? Do we worry about things getting lost or delayed?


DR. JESSICA NOUHAVANDI: All great questions. My background is in retail pharmacy. So I operated as a pharmacist in a brick and mortar for many, many years in a small town before starting Honeybee. And like many of your listeners, I had my doubts too, but I can safely say that we have the same relationship that we had with our patients, through our dashboards, through communications, through chat and phone. You actually have a more direct line of communication with your pharmacist.


It's absolutely safe. We have a satisfaction guaranteed. So, if anything gets lost in the mail because of course that happens, right? The USPS has been having some trouble lately, as we all know, but it's absolutely safe. If we got the prescription and everything checks out, you should get your medication within two to three days.


We do have a dashboard that you can log into and see your refills and see all the information, what the manufacturer you got was. I mean, we make it very easy for you to have better control over your healthcare. A lot of times, at a big box chain, you really don't know what's happening behind the counter, and we really make an effort to open that up to you as our patients. And again, satisfaction guaranteed all the time and a direct line of communication with pharmacists, with patient support advocates.


I would argue that it's a better experience.


Three-Month Refills and Splitting Pills


MARY SHOMON: So, we’ve talked about how to save using your copay, direct programs, and by paying retail cash price. Let’s look at some other ways to save.


One possible way to save on medications is to get a three-month supply, instead of month-by-month refills. It’s not always that simple, however. Chris DiLascia explains:


CHRIS DILASCIA: Some of the manufacturers offer a better cash price for a three-month supply. On the other side of the equation, if the patient has insurance, most insurance plans have rules about whether or not they allow you to get a three-month supply.


In most cases, if you're buying it, if you're getting a prescription filled at your local drug store, they will have a 30-day limit and you will not be able to get a three-month supply. That being said, if it's a chronic medication like blood pressure medications, like thyroid, in all likelihood the health plan will have a mail order plan that you can opt into, and that will allow your prescriptions to be filled by mail centrally, generally by a mail order pharmacy,


The big insurance companies like Aetna will have their own mail order pharmacy. And they generally will encourage patients, by providing discounts, to go into their mail order programs, because it does save quite a bit of filling it once and then having it refilled four times a year, as opposed to having it refilled every month. And there's also special incentives that they get from the manufacturers as well, because mail order pharmacies tend to drive better patient adherence, or at least that's the theory.


MARY SHOMON: One way to get around the limitations from insurance companies is to go directly to a retail mail-order pharmacy and pay the cash price for a three-month refill, as Dr. Jessica explains.


DR. JESSICA NOUHAVANDI: Because we don't work with insurance or any other middlemen, we don't share your information with anybody else, we’re actually able to get you a three-month supply without any problem. And that's one of the things that I really love to tell my patients about, because staying consistent and not missing a dose is really, really important as well. I always push my patients to get a three-month supply at a time. And, that's something that we do for a lot of our patients. Normally it's very difficult to get three months’ supply through your insurance, because they won't cover that much at a time. But at Honeybee because we don't work with anybody else, we're able to get you a larger supply, so you can put your mind at ease for a time period.


MARY SHOMON: It's also frustrating to have to go get refills or to remember to get refills every month because your insurance won't let you get more than one month at a time. And also, with the mail order, if you know you have a three-month supply and you reorder in time, you're not going to be worried about any delays in treatment, if you'll give yourself enough time and you'll always have some medication on hand, to cover any crossover time. I think it's a really great option that people really need to be aware of and it's perfectly timed for the world that we live in right now, because everybody wants to save money on getting good quality medications and good quality healthcare. And I'm excited to see where Honeybee goes in the future, because I think that this is definitely a service that is going to be around for quite a long time.


MARY SHOMON: Another way we’re told to save money on medications is to split pills. But, as TPS’s Chris DiLascia explains, it’s not always the best idea from a therapeutic standpoint.


MARY SHOMON: And what about splitting pills? Because I know that with some medications, it's not that troublesome if it’s a tablet and it has an easy score, people can cut them in half and split pills as a way to save money.


But I know that in some cases it's not recommended. For example, I know with thyroid, they're not really recommending it because, in some cases, they want that narrow therapeutic range of treatment and splitting means that you're not always going to get an even split. Do you have any thoughts in general about splitting pills?


CHRIS DILASCIA: The idea that you can split a pill exactly down the middle and get exactly half the dose is Fantasy Island. For medication like a thyroid medication splitting a pill could get you into trouble.


There are some long acting pills out there as well. When you split them in half, you break the outside seal of the tablet, that’s supposed to protect it from the gastric juices until it gets to your intestines, for example. And now you're going to get a dose dump that you otherwise wouldn't have gotten. So sustained release products shouldn't be split either.


So, you'll find in the package insert and generally your physician or pharmacist will know whether or not a tablet is able to be split. And then the second piece of that puzzle is, am I going to get enough medication in one half of the tablet? Or am I going to get too much in one half and too little in the other? On occasion I split tablets at home for different things, but I only split the ones that I know it doesn't really make a difference.


Ask the Pharmacist


MARY SHOMON: Finally, one of the most important things you can do is to find a pharmacist you trust, whether it’s a local pharmacist or an online pharmacist, and reach out to ask questions. If you have a good relationship with your pharmacist, they can help you navigate the process more successfully. I discussed this with Dr. Jessica.


One tip that I'm always telling patients and it applies to any prescription you get, not just thyroid, is always ask the pharmacist, “Which is cheaper, my copay or the retail price of this medication?” Because oftentimes you're going to find out you could pay significantly less if you just paid the cash retail price than if you paid your copay price. For some patients, they may want to get to their deductible, they may be close enough to getting to it so that they want that to apply to the deductible, in which case it's a reasonable decision to decide to put it through and pay the copay, if they're looking at trying to get to a deductible. But for some of us, the deductible is so high, we're never going to get to it. So why not save money along the way?


I also am a firm advocate of knowing the full price situation before you go to get that refill, or before you go get a new prescription filled. Look it up, look on Honeybee and find out what the mail order price is. Check the GoodRx and the SingleCare prices. Get the lay of the land of what all the different options are, so that you're making an informed decision and can choose the best option for you.


DR. JESSICA NOUHAVANDI: Absolutely. And talk to your pharmacist. At Honeybee, we have pharmacists ready to talk to patients six days a week. And I think that's important too. In big box chain pharmacies, oftentimes the pharmacists don't have a lot of time, but it's essential that you have a relationship with your pharmacist, and that he or she understands what you're taking and what works for you. So open that dialogue, open that conversation. If you're at a pharmacy where they don't have time, time to change.


MARY SHOMON: Chris DiLascia also emphasizes the importance of connecting with a trusted pharmacist.


CHRIS DILASCIA: Do a little homework, but also ask your pharmacist. You don't necessarily want to be pushed in a direction that maybe isn't therapeutically good for you, but if you have a pharmacist that you trust. I've always gone a lot of times to independent pharmacies because they tend to be more service-oriented, because they're not volume driven, like some of the bigger chains. Not to say the chains don't do the same thing, but I'm just saying, find a pharmacist you trust, because in many cases you can ask the pharmacist.


There’s a lot of interesting things that pharmacists can do to help you save money, that will keep you on the right therapeutic track and maybe actually improve your therapeutic track.


You Have a Choice!


MARY SHOMON: As a thyroid patient, you have rights. You have the right to get the medication that works best for you. Pharmacies or health insurance companies should not be able to prevent you from getting the medication that you and your doctor know is best for you. At the same time, you should be able to find out how much that medication will cost, and not have that cost change widely from month to month. You should also be able to afford it. And you should never have to pay more with your insurance copay than you’d pay retail without it.

To exercise these rights, however, you are going to have to do some groundwork. You’ll need to get familiar with the different prices for your medications, and I hope you learned some new ways to do that in this episode of the podcast. You’ll also need to take advantage of the creative ways to get your meds at the best prices.

And, perhaps the most important thing I’d like you to take away from this episode is that you always have a choice. Dr. Jessica explains it well.


DR. JESSICA NOUHAVANDI: By the way, you have a choice. There's always a choice. And I think that the insurance companies, the PBMs, a lot of the people involved in our world make it seem as if there's only one choice: your copay or bust. And that's not the case. You have choices and I'm so glad there's people like you, Mary, who are patient advocates, and so many others, that are spreading the word about choice and options out there. It's not the end of the road. If you can't afford your copay or you can't afford what they're telling you at the counter, there's other options out there.


MARY SHOMON: I hope you are coming away from this episode feeling more empowered, knowing how to get the thyroid medication you need, at prices that may be far more affordable than what you’re currently paying. Above all, don’t get stuck taking something that’s not working for you, or getting the runaround from pharmacies and health insurance companies. There are options. And you deserve every chance to feel and live well.


I want to thank my guests, Dr. Jessica Nouhavandi of Honeybee Health, and Chris DiLascia, of Transition Pharmacy Services, for sharing their pharmacy expertise and perspectives

You’ll find Honeybee Pharmacy is online at www.honeybeehealth.com. You can also find them on social media, HoneybeehealthRX_. You can find out more about Transition Pharmacy Services at https://www.transitionrx.com. These links, along with a complete transcript of this episode, and other helpful resources and links, are all available at the Thyroid Deep Dive website, www.thyroiddeepdive.com.


And remember that every episode of the Thyroid Deep Dive podcast has the same goal: to provide you with practical information that will help you enjoy the very best health possible. You can subscribe and listen at all your favorite podcast platforms.


This is Mary Shomon, and I want to thank you for listening to the Thyroid Deep Dive. Today, and every day, may you feel well and live well.



Resources and Links


"Saving Money on Your Thyroid Drugs With Copay Cards and Manufacturer Coupons" - by Mary Shomon - https://www.palomahealth.com/learn/thyroid-drugs-copay-cards


Direct Enrollment Savings Programs

Prescription Coupons & Savings

Honeybee Health

Transition Pharmacy Services (TPS)



The Levothyroxine Deep Dive is a free, comprehensive educational program that covers everything you need to know about levothyroxine treatment for hypothyroidism. The program includes an online guide, a multi-part video webinar, and a downloadable book, available at no cost. See https://www.mary-shomon.com/dive to access the program at no cost.


The Natural Thyroid Guide is a free, comprehensive educational program that covers everything you need to know about natural desiccated thyroid (NDT) treatment for hypothyroidism. The program includes an online guide, a video webinar, and a downloadable book, available at no cost. See https://www.naturalthyroidguide.com to access the program at no cost.



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The Levothyroxine Deep Dive is a free, comprehensive educational program that covers everything you need to know about levothyroxine treatment for hypothyroidism, including information about Synthroid, Levoxyl, and Unithroid tablets, Tirosint capsules, Tirosint-SOL oral solution, and generic levothyroxine tablets. The program includes an online guide, a multi-part video webinar, and a downloadable book, available at no cost. See https://www.mary-shomon.com/dive to access the program at no cost.

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The Natural Thyroid Guide is a free, comprehensive educational program that covers everything you need to know about natural desiccated thyroid (NDT) treatment for hypothyroidism, including information about Armour Thyroid, Nature-throid, WP Thyroid, and NP Thyroid. The program includes an online guide, a video webinar, and a downloadable book, available at no cost. See https://www.naturalthyroidguide.com to access the program at no cost.