Can I get this as a generic? Is the co-pay really that high? Will you match Wal-Mart's $4 price? ''I'm out of Lexapro,'' a woman pleaded one recent Tuesday, speaking of her antidepressant. ''Can I just have four pills until payday on Friday?''
Some customers request prices for a fistful of prescriptions, and then say they can fill only the cheapest two. Others ask which are most important.
''It can be a hard question to answer,'' said Traci W. Suber, the head pharmacist. ''The only thing I can do is let them know what they're for, get them the cheapest available and encourage them to come back for the others when they can.''
Even with the Medicare drug benefit, even with the prevalence of low-cost generics, even with loss-leader discounting by big chains, many Americans still find themselves unable to afford the prescription medications that manage their life-threatening conditions.
In downtrodden communities like Rocky Mount, where unemployment has doubled to 14 percent in a year, the recession has heightened the struggle. National surveys consistently find that as many as a third of respondents say they are not complying with prescriptions because of cost, up from about a fourth three years ago.
Many customers at Almand's Oakwood neighborhood store, particularly those too well off for Medicaid but unable to afford insurance, simply pick and choose among risks. They weigh not taking maintenance medications against more immediate needs like shelter and food.
The pharmacists see it every day. About eight months ago, they stopped automatically preparing refills for regular customers because they found that more than half were not being collected and had to be restocked.
One recent Wednesday, James S. Crawford, newly discharged from the hospital after his third heart attack, fanned six green slips across the counter as if showing a hand of cards. There were a pair for high blood pressure, one each for angina, cholesterol, and acid reflux, and a renal vitamin for his kidney disease. ''I need to know the prices,'' he said.
Ms. Suber, the pharmacist, explained what each drug was for and listed the co-payments under Mr. Crawford's Medicare plan, ranging from $8.25 to $18.49 for a one-month supply. The renal vitamin, at $21.89, was not covered.
Mr. Crawford, 61, who makes do on $1,800 a month in Social Security and veterans' benefits, decided he could afford only the heart, blood pressure and acid reflux pills. ''If I can rob a bank,'' he said, chuckling, ''I'll be back for the others.''
Before leaving, he handed over yet another prescription, just for safekeeping. It was for Plavix, an anticlotting drug that helps coronary patients avoid new blockages, and it had been written in early February after Mr. Crawford's second heart attack. At $160, the co-payment was so high he had never considered filling it.
Some customers get by through a patchwork of assistance programs offered by governments, charities and drug makers. The only hospital in Rocky Mount, Nash General, donated about $60,000 in medications last year, and a newly established free clinic is spending up to $600 a month on discounted prescriptions at Almand's.
But the need is much greater, and the impact is already felt downstream in clinics and emergency rooms where the ailing seek treatment when their diabetes or blood pressure spikes out of control.
Dr. John T. Avent, a physician at a low-income clinic near Almand's, estimated that at least 80 percent of his patients were not taking prescribed medicines.
''They'll say, 'Well, Doc, I just couldn't afford it; I've been out of it for a month now,' '' Dr. Avent said. ''By that time, of course, their blood pressure is highly elevated and their hemoglobin A1C is two to three times what it should be.''