Health & Fitness

A prescription for sticker shock

Americans are using more prescription drugs than ever, even as prices rise and insurance obstacles proliferate.
Americans are using more prescription drugs than ever, even as prices rise and insurance obstacles proliferate. The New York Times

There are millions of people out there, like me, who are frustrated with the maddening obstacles to obtaining prescribed medications with your insurance.

My doctor calls the system Byzantine, a rip-off in which the government, including Medicare, is not permitted to negotiate costs with drug companies, instead allowing them to charge whatever they think the market will bear.

“Escalating drug prices have alarmed physicians and the American public and led to calls for government price controls,” Peter J. Neumann and Joshua T. Cohen of Tufts University Medical Center wrote last week in The New England Journal of Medicine.

Most manufacturers maintain that drug prices should be based on research, development and production costs, but Neumann and Cohen suggested that these costs should reflect the value the drugs provide, including such factors as health benefits and cost-effectiveness.

The rising cost of prescription drugs is especially worrisome given the recent escalation in their use in the United States.

Elizabeth D. Kantor, an epidemiologist at Memorial Sloan Kettering Cancer Center, and her colleagues recently reported in JAMA that from 1999 to 2012, the number of American adults using prescription drugs rose to 59 percent from 51 percent, and those who took five or more medications increased to 15 percent from 8.2 percent.

The increases, which occurred in 11 classes of drugs, persisted even when the rising age of the population was considered.

The researchers arrived at their numbers by analyzing seven cycles of the National Health and Nutrition Survey, each involving personal interviews with thousands of adults.

Increased drug use and obesity

Americans today are using more drugs than ever to lower cholesterol, blood pressure and blood sugar, treat depression and pain, control acid reflux and breathing problems, and relax muscles.

Among other concerns, the findings “raise the question of how much the rise in obesity is affecting increased drug use,” Kantor said in an interview. “As obesity continues to rise and people develop the consequences, it remains to be seen how effective drugs are in treating them.”

Using drugs to treat the consequences of unhealthy living habits contributes to rising health care costs that neither the government nor the public can control.

Unfortunately, it is likely to take an act of Congress to change the current system, so we’re all stuck with it for some time to come, perhaps indefinitely. Within the system, however, it pays to know how to get what you need at the lowest cost and with the fewest hassles.

Every drug insurer has its own annually issued “formulary” — a booklet listing the drugs it will cover during the year and the required copay. Some policies also have large deductibles that force consumers to shell out hundreds of dollars starting in January for needed medications.

It is not unusual for consumers to need a new drug that doesn’t happen to be in their insurance company’s formulary, though the insurer must cover it until the end of the year, when policyholders may be able to switch to a different insurer. (People who obtain medical and drug insurance through an employer-funded health plan are most likely stuck with those plans.)

Furthermore, companies change their formularies each year, adding drugs or, more likely, deleting ones previously covered.

I get my drug insurance through Medicare Part D. But since signing up in 2006, when the program began, I’ve had many hassles with the company that was suggested to me by the Medicare adviser I consulted on the phone.

Among other issues (like the company denying coverage because it erroneously insisted I had other drug insurance), the most expensive of the four medications I use — the only one not available generically — is not included in that company’s formulary.

The company suggested two alternatives that my doctor and I knew were medically inadvisable. So he had to file an appeal every year to have the drug covered (albeit at a high copay), and when that was denied, he had to file a second appeal.

What an aggravation and a waste of medical office time.

During the current enrollment period, from Oct. 15 to Dec. 7, I decided to switch to another insurer. Since everyone with a computer is supposed to be able to do this, I gave it a try.

I am happy to report that, despite the problems many consumers initially had signing up for insurance under the Affordable Care Act, the government did a great job with the website for Medicare Part D. Expecting the task to take hours, I enrolled with a new company in about 15 minutes. I followed the links to “Sign Up/Change Plans” on medicare.gov.

You start by entering your ZIP code and answering two questions about your Medicare coverage. (Be sure to have your subscriber number handy.) Type in the name of each prescription drug you take, up to 25, as well as the dosage, quantity and frequency, and whether you get it from a pharmacy or by mail order.

If you choose a pharmacy, you are given a list of those near your home (the distances vary depending on your ZIP code). You’re then asked to select the desired type of Medicare and drug plan. I selected “drug plan with original Medicare.”

You can then refine your search according to such options as “limit to the monthly premium” (up to $290), “limit to annual deductible” (up to $360) and the company’s rating (I chose one with four stars out of five, the highest among the companies that fit my criteria).

The next screen estimated my annual drug and health care costs. Nineteen Part D plans were found in my ZIP code, listed from least to most expensive.

For each company, the website showed my estimated annual drug costs if purchased retail or by mail order (cheaper by mail); the monthly premium, which in my case is deducted from my Social Security benefit; the annual deductible, if any; the drug copay amount; whether all my drugs are in the company’s formulary; and the company’s star rating.

By the way, if you can get your prescriptions written for a 90-day supply, the cost is usually less than that of a 30-day supply refilled twice.

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