The cost of prescription drugs is a major topic of conversation amongst Migraineurs and other patients who need prescription medications. Even for those who have insurance that covers medications, the amount paid by the patient has increased to consume a disproportionate amount of patient income and has left many patients with difficult medical and financial choices to make. Part of this phenomenon is coverage limits that affect the number of doses of triptans that are covered per month, a number that has recently been decreasing.
A review of previous studies indicates that an increase in prescription drug cost sharing is associated with a decrease in drug spending and use of pharmacies; and for some chronic conditions, higher cost sharing is associated with greater use of expensive medical services (doctor appointments, emergency care, hospitalization, etc.), according to an article in the July 4, 2007, issue of JAMA.
“… with recent increases in pharmacy spending, pharmacy benefit managers and health plans have adopted benefit changes designed to reduce pharmaceutical use or steer patients to less-expensive alternatives. The rapid proliferation of mail-order pharmacies, mandatory generic substitution, coinsurance plans, and multi-tiered formularies has transformed the benefit landscape.”1
Before we proceed, let’s define some of the terms used in this review:
- cost sharing – patient and insurance companies sharing the cost of prescription medications through copayments
- insurance formularies – lists of medications that insurance companies prefer. Some insurance companies limit payment to medications listed on their formularies. Example: Some insurance companies list only certain triptans on their formularies. Those not listed may not be covered.
- multi-tiered formularies – formularies listing medications on more than one level or tier. The amount the insurance company will pay on a prescription is often based on which tier the medication falls under. Example: If Imitrex is on tier 1, and Frova is on tier 2, the insurance company may pay a larger portion of the cost of a prescription for Imitrex and a lower portion for Frova.