The hospital bill and the pharmacy counter are two different bills. The hospital sends its charges to the insurer and to your parent. The pharmacy charges whatever the plan allows at the counter that day, and that number depends on rules the hospital never sees. This guide is about the second bill, the one that shows up in the first week after discharge.

Local option: New Plan Care gives families in the St. Louis area in-home help so a parent can stay home: companionship, help with bathing and dressing, meals, and overnight care. Call (314) 405-0887.

Day 0: Get the Medicine List in Writing

Before anyone leaves the room, ask for the discharge medication list in writing. Ask the nurse or the discharge planner which items are new, which are changed, and which are the same as before the hospital. Ask whether each new prescription was sent electronically, and to which pharmacy. The list tells you what you are pricing. Without it, the pharmacy can only price what it can see, and that may not be the full set.

Ask the pharmacist, not only the doctor's office, whether the prescriptions have arrived and whether any of them need a prior authorization, which is a step the plan requires before it will pay. Ask how many days of supply each fill covers. A first fill is sometimes a short supply, and the next fill may be priced differently.

Day 1: Check the Plan Before the Counter

When the car pulls in and the first pickup is an errand, bring the plan card, a photo ID, and the written list. Check whether the pharmacy is in your parent's plan network. An out-of-network pharmacy can change the price at the counter, and the plan may not pay for the fill at all. Ask the pharmacy to run the claim and show you the plan's share and your share, line by line, before you pay.

Ask one more question at the counter: is there a cash price lower than the plan copay for the same medicine, and if you pay cash, does that purchase count toward the plan's deductible or out-of-pocket limit? Those are two different answers. A cash purchase can save money now and still leave the plan's running total where it was. Write both answers down.

What Moves the Number

Four things set the price at the counter, and you can check each one.

The plan's tier for the medicine. Each plan sorts covered medicines into tiers, and each tier carries its own copay or coinsurance. Look the medicine up in the plan's formulary, which is the plan's list of covered drugs. Being on the list does not tell you the cost. The tier does.

Where the plan year stands. A deductible resets at the start of the plan year. If your parent has not yet met the deductible, the first fill may cost more than the copay you expect. If the deductible is already met, the same fill may cost less. Ask the pharmacy or the plan member services number on the card where the deductible stands.

Coverage rules. Some plans limit the quantity per fill, require a prior authorization, or ask the prescriber to try a different medicine first. Each rule adds a call and sometimes a delay. Ask which of these apply before the car leaves the lot.

Pharmacy choice. The same medicine can post different prices at different pharmacies, and a preferred or mail-order pharmacy listed by the plan may charge less than another counter. Ask which pharmacies the plan prefers. Ask whether the pharmacy you are standing at offers refill synchronization or delivery.

Day 2 to Day 3: Keep One Record

Start a single page. Write the date, the medicine name as the pharmacy lists it, the plan's share, your share, the cash price if one was quoted, and who approved the choice. Keep the pharmacy receipt and the plan's statement when it arrives. This is the record you will use if a charge looks wrong, and it is the record that tells you what the next fill is likely to cost.

Check the plan's statement against the pharmacy receipt. They should describe the same fill. If they do not match, call the plan member services number on the card and ask what was billed and why. If the answer is a denial, ask for the reason in writing.

Day 3 to Day 7: Plan the Next Fill

Before the first supply runs low, find out the refill date and what the next fill will cost. If the pharmacy offers to line up refill dates, ask about it. Fewer trips can mean fewer surprise totals at the counter, but ask the pharmacist whether any of the medicines has a shorter fill window that would cancel that benefit.

If the cost is more than the family can carry, do not change or stop a medicine on your own. Call the prescriber's office and the pharmacist first. Ask whether the plan has an exception process, whether a different medicine on a lower tier is an option for your parent, and what the plan's appeal steps are for a denied claim. Those questions belong to the prescriber, the pharmacist, and the plan. Your job is to bring the record and the list.

Who Answers What

The pharmacist answers the counter price and the fill rules. The plan answers the deductible, the tier, the denials, and the appeal steps. The prescriber answers whether a different medicine is an option for your parent. The discharge planner answers which medicines are new. Keep those four names in one place so you know which phone to call.

For local help with the rest of the discharge, see Local Help After a Discharge. For the order of the first two weeks, the Day 0 to Day 14 After Discharge page lays it out. The sources behind these checks are on the Sources page.

The Prescription Counter Sets a Second Bill: What Moves Your Parent's Out-of-Pocket Cost in the First Week