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Insurance Companies Shifting Drugs to “Non-Preferred” to Raise Co-Pays

Health insurance companies can no longer deny patients coverage because of pre-existing conditions, but there’s no denying we’re expensive to insure. The latest strategy to increase profit is shifting even generic medications to “non-preferred” status, according to a story by ProPublica and The New York Times’ The Upshot. Patients pay higher co-pays for non-preferred medications. For some illness, all generics are listed as non-preferred. Migraine is mentioned in the story, which probably means triptans will be shifted to non-preferred (which could affect people with cluster headache as well).

Here’s the report in full, republished with permission:

A New Way Insurers are Shifting Costs to the Sick

By charging higher prices for generic drugs that treat certain illness, health insurers may be violating the spirit of the Affordable Care Act, which bans discrimination against those with pre-existing conditions.
by Charles Ornstein
ProPublica, Sep. 17, 2014, 11 a.m.

Health insurance companies are no longer allowed to turn away patients because of their pre-existing conditions or charge them more because of those conditions. But some health policy experts say insurers may be doing so in a more subtle way: by forcing people with a variety of illnesses — including Parkinson’s disease, diabetes and epilepsy — to pay more for their drugs.

Insurers have long tried to steer their members away from more expensive brand name drugs, labeling them as “non-preferred” and charging higher co-payments. But according to an editorial to be published Thursday in the American Journal of Managed Care, several prominent health plans have taken it a step further, applying that same concept even to generic drugs.

The Affordable Care Act bans insurance companies from discriminating against patients with health problems, but that hasn’t stopped them from seeking new and creative ways to shift costs to consumers. In the process, the plans effectively may be rendering a variety of ailments “non-preferred,” according to the editorial.

“It is sometimes argued that patients should have ‘skin in the game’ to motivate them to become more prudent consumers,” the editorial says. “One must ask, however, what sort of consumer behavior is encouraged when all generic medicines for particular diseases are ‘non-preferred’ and subject to higher co-pays.”

I recently wrote about the confusion I faced with my infant son’s generic asthma and allergy medication, which switched cost tiers from one month to the next. Until then, I hadn’t known that my plan charged two different prices for generic drugs. If your health insurer does not use such a structure, odds are that it will before long.

The editorial comes several months after two advocacy groups filed a complaint with the Office of Civil Rights of the United States Department of Health and Human Services claiming that several Florida health plans sold in the Affordable Care Act marketplace discriminated against H.I.V. patients by charging them more for drugs.

Specifically, the complaint contended that the plans placed all of their H.I.V. medications, including generics, in their highest of five cost tiers, meaning that patients had to pay 40 percent of the cost after paying a deductible. The complaint is pending.

“It seems that the plans are trying to find this wiggle room to design their benefits to prevent people who have high health needs from enrolling,” said Wayne Turner, a staff lawyer at the National Health Law Program, which filed the complaint alongside the AIDS Institute of Tampa, Fla.

Turner said he feared a “race to the bottom,” in which plans don’t want to be seen as the most attractive for sick patients. “Plans do not want that reputation.”

In July, more than 300 patient groups, covering a range of diseases, wrote to Sylvia Mathews Burwell, the secretary of health and human services, saying they were worried that health plans were trying to skirt the spirit of the law, including how they handled co-pays for drugs.

Generics, which come to the market after a name-brand drug loses its patent protection, used to have one low price in many insurance plans, typically $5 or $10. But as their prices have increased, sometimes sharply, many insurers have split the drugs into two cost groupings, as they have long done with name-brand drugs. “Non-preferred” generic drugs have higher co-pays, though they are still cheaper than brand-name drugs.

With brand names, there’s usually at least one preferred option in each disease category. Not so for generics, the authors of the editorial found.

One of the authors, Gerry Oster, a vice president at the consulting firm Policy Analysis, said he stumbled upon the issue much as I did. He went to his pharmacy to pick up a medication he had been taking for a couple of years. The prior month it cost him $5, but this time it was $20.

As he looked into it, he came to the conclusion that this phenomenon was unknown even to health policy experts. “It’s completely stealth,” he said.

In some cases, the difference in price between a preferred and non-preferred generic drug is a few dollars per prescription. In others, the difference in co-pay is $10, $15 or more.

Even small differences in price can make a difference, though, the authors said. Previous research has found that consumers are less likely to take drugs that cost more out of pocket. “There’s very strong evidence for quite some time that even a $1 difference in out-of-pocket expenditures changes Americans’ behavior” regarding their use of medical services, said the other co-author, Dr. A. Mark Fendrick, a physician and director of the University of Michigan Center for Value-Based Insurance Design.

Fendrick said the strategy also ran counter to efforts by insurance companies to tie physicians’ pay to their patients’ outcomes. “I am benchmarked on what my diabetic patients’ blood sugar control is,” he said. “I am benchmarked on whether my patients’ hypertension or angina” is under control, he said. Charging more for generic drugs to treat these conditions “flies directly in the face of a national movement to move from volume to value.”

If there are no cheaper drugs offered, patients might just skip taking their pills, Fendrick said.

The authors reviewed the drug lists, called formularies, of six prescription drugs plans: Harvard Pilgrim Health Care in Massachusetts; Blue Cross Blue Shield of Michigan; Blue Cross and Blue Shield of Illinois; Geisinger Health Plan in Pennsylvania; Aetna; and Premera Blue Cross Blue Shield of Alaska. They wanted to see how each plan handled expert-recommended generic drugs for 10 conditions.

The conditions are not all high cost like H.I.V. and Parkinson’s. They also include migraine headaches, community acquired pneumonia and high blood pressure.

Premera and Aetna had preferred generic drugs for each of the 10 conditions the authors examined. Harvard Pilgrim, a nonprofit often considered among the nation’s best, did not have a lower-cost generic in any of the 10 categories.

Four of the six plans had no preferred generic antiretroviral medication for patients with H.I.V.

In a statement to ProPublica, Harvard Pilgrim said it charges more for some generics because they are more expensive. The cheapest generics carry a $5 co-payment for a 30-day supply. More expensive generics range from $10 to $25, or 20 percent of the cost for a 30-day supply. The health plan said its members pay less for their medications than the industry average.

Blue Cross and Blue Shield of Illinois said that its preferred generics had no co-payment at all, and that non-preferred generics cost $10. “We historically only had one tier of generic drugs at a $10 co-pay,” the spokeswoman Mary Ann Schultz said in an email.

The Blue Cross Blue Shield of Michigan spokeswoman Helen Stojic said the editorial looked only at its drug plan for Medicare patients, which the government closely regulates. Under Medicare, patients can appeal a drug’s tier and seek to pay a lower co-payment, she said.

Geisinger did not respond to questions.

Health plans that participate in Medicare’s prescription drug program, known as Part D, have been moving rapidly to create two tiers of generic drugs. This year, about three-quarters of plans had them, according to an article co-written by Jack Hoadley, a health policy analyst at Georgetown University’s Health Policy Institute. The practical effect of such arrangements probably varies based on the difference in cost, he said.

Dan Mendelson, chief executive of Avalere Health, a consulting firm, has studied the way in which health insurers structure their benefits. He said the increasing number of drug tiers in some plans was confusing for patients.

“Consumers often don’t understand which drugs are where,” he said. “They don’t understand the purpose of tiering. They just get to the pharmacy counter and it gets done to them.”

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Hormonal Birth Control for Menstrual Migraine & Insurance Denials

Despite the Affordable Care Act’s required coverage of birth control, some insurers are denying coverage of the birth control patch or NuvaRing, NPR reports. There are a few exceptions to the rule, but nearly all health plans are required to cover all FDA-approved birth control. If you have been denied coverage, NPR recommends appealing the denial and contacting your state insurance board.

How is this relevant to headache/migraine/chronic illness? Hormonal birth control is one method of managing menstrually associated migraine attacks, which tend to be more severe than the migraines a woman has other times of the month. The patch and the ring provide a steadier dose of hormones than a pill does, which makes them more effective for this purpose.

I’ve been using NuvaRing continuously (with one-week breaks every three or four months) since January 2010 and it has been tremendously helpful. Now, the most severe migraines I get happen the few times a year I have to stop the ring for a withdrawal bleed. (You can learn more about skipping periods on The Well-Timed Period.)

This method is generally not recommended for women who have migraine with aura, who are at greater risk of stroke if they use hormonal birth control. However, I recommend talking it over with your headache specialist to decide if it is a good option for you, whether you have migraine with or without aura. Given the frequency and severity of my migraines, my headache specialist said he’d advise me to continue using the NuvaRing even if I did have migraine with aura.

(If you don’t want to/can’t use hormonal birth control for some reason, triptans can be used to prevent menstrual migraine attacks.)

I always love to read your comments, but I’m on vacation and won’t be able to reply until the week of Sept. 8. Please don’t think I’m ignoring you!

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Great Price on Sumatriptan (Imitrex) at Health Warehouse

HealthWarehouse, a licensed U.S. pharmacy based in Kentucky, charges even less for sumatriptan than Inhouse Pharmacy Europe, which I told you about last week. Bonus: it’s entirely legit and there’s no question if it’s legality, though you’ll need to send them a prescription.

I’ve ordered other meds from Health Warehouse and have been pleased with the service. The prices are low and shipping is prompt. The only drawback is that they don’t take manufacturer’s coupons.

Wherever you buy sumatriptan, you can try to simulate the effect of Treximet by taking naproxen sodium (Aleve) along with it. (See paragraph five of Save Money on Sumatriptan (Imitrex/Imigran/Treximet) for details.) Some people find mixing their own medication cocktail is as effective as Treximet, others swear by the all-in-one Treximet. It’s worth a try to save money, but be sure to let your doctor know what you’re up to — safety is even more important than frugality!

Thanks to The Daily Headache reader on Facebook who told me about HealthWarehouse’s price on sumatriptan. And thanks to Timothy who suggested asking your doctor for triptan samples at every visit and thanking them profusely for them. He also pointed out that if you take a low dose of a medication, you can ask your doctor to write a prescription for a higher dose and split the pill in half. This doesn’t work with every medication (some have a time-release coating, others aren’t tablets, others don’t come in a dose that’s easily halved, etc.), but it’s something to ask your doctor about.

If you know any other sources for good prices on sumatriptan — or any other meds! — please leave a comment. Your help is invaluable to me and to other readers as well.

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Save Money on Sumatriptan (Imitrex/Imigran/Treximet)

I’ve been debating posting this for months. I hesitate because I doubt getting triptans without a prescription from another country by mail order is legal, even though the drug is available over-the-counter in that country. On the other hand,  knowing of a resource for inexpensive triptans and not sharing it seems unfair to readers who delay or avoid treating migraines because of the high cost of abortive drugs. I’m sharing this with the caveat that the legality is fuzzy, so you’ll have to make that ethical decision for yourself. Here’s the FDA’s stance on drug importation.

Imitrex (Imigran in the UK) and Treximet are expensive. Even though sumatriptan, the main ingredient in both, is available as a generic, it’s still tough to find it for less than $3 for a 50 mg pill. Prices for higher doses or injections skyrocket from there. If you’re looking to save on Imitrex or Treximet, check into pricing at Inhouse Pharmacy Europe, which has 50 mg tablets of sumatriptan for $1.10 each. Higher doses and injections are also available for less than in the US. Because sumatriptan is available over-the-counter in the UK, which is the jurisdiction this pharmacy operates under, you don’t need a prescription to order it.

I can’t vouch for the company directly because I don’t use sumatriptan and haven’t ordered from them myself, but this recommendation comes from a friend and longtime reader who has been ordering from the company for at least five years without a problem. She says the company is very reliable and medications are never close to their expiration date. In fact, the website tells you the expiration date of the meds they are currently shipping. Shipping is free to the US and they provide package tracking information.

If you use Imitrex, you can substitute these directly according to the strength you are usually prescribed. They are the same thing.

If you use Treximet, you can try taking sumatriptan with 500 mg of the OTC painkiller naproxen sodium (Aleve) to approximate the drug. Treximet contains 85 mg of sumatriptan, while sumatriptan only comes in 50 mg and 100 mg, so you’ll have to choose which you prefer. GSK’s marketing materials say that having the two drugs combined into one tablet is more effective than taking each one separately. But if you’re holding off on taking triptans because they’re too expensive, you may be more likely to take them early in an attack (when they’re most effective) if they don’t cost an arm and a leg.

Not needing a prescription is a double-edged sword, of course. You still need to take them judiciously and watch out for medication overuse headache. Be sure you tell your doctor how frequently you’re taking them, even though you can get them without a prescription.

If you place an order with Inhouse Pharmacy Europe, please leave a comment letting readers know what your experience is. I hope it turns out to be a helpful source for helping readers afford these pricy meds.

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Docs the Target in New War on Drugs?

Is the DEA going after doctors who prescribe painkillers because the war on street drugs hasn’t proven successful? A New York Times columnist makes this connection in Handcuffs and Stethescopes.

“As quarry for D.E.A. agents, doctors offered several advantages over crack dealers. They were not armed. They were listed in the phone book. They kept office hours and records of their transactions. And unlike the typical crack dealer living with his mother, they had valuable assets that could be seized and shared by the federal, state and local agencies fighting the drug war.”