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Why are some medications still so expensive despite having insurance coverage?

Kelley-Ross Pharmacy GroupBlogWhy are some medications still so expensive despite having insurance coverage?
25
Oct
2019
25.10.2019

Many people have found themselves in the following situation…

You arrive to your local pharmacy after a long-awaited visit to your doctor’s office regarding a health condition you have been battling for years. Amazingly your doctor shared that there is a new drug released into the market that can treat this rare condition you have just been diagnosed with. This drug has displayed promising results through numerous clinical trials and seems to be well tolerated. At the pharmacy counter, the pharmacy employee presents the new medication bottle along with the label displaying the copay amount that you must pay in order to walk out the door with this medication. To your disbelief, you see a whopping $350 listed as the amount owed for a 30-day supply and question if the medication was billed through your private insurance plan in which you have placed confidence in for years. After speaking with the pharmacist, you discover that because this medication is brand only and there are no generic equivalents available, the cost of the medication is expected to be high while the drug manufacturer still has a monopoly, despite running it through the insurance plan. You find yourself in this situation where you either fork out $350 for a 30-day supply of this medication or take no medication at all and continue living with this disease.

 

Let’s sparse out a few definitions to help explain what is going on in this situation…

This person has a health insurance plan through their employer that provides prescription drug coverage. Most health insurance plans, require the patient cover some out of pocket costs such as a co-pay, co-insurance, and deductibles (which are a specified amount the patient must pay out of pocket before the insurance starts covering services). Usually, the copay will be a set amount owed for each prescription after the insurance covers a portion of the cost. Sometimes co-pays can start out high if there is deductible to meet by a certain time in the year. Co-insurance is usually a percentage of the drug cost that the patient is responsible for paying with each fill. Generally, co-pays tend to be minuscule ranging from cents to dollars for common, generic medications that have been on the market for awhile.

Now the story changes when brand name medications arrive…

The challenge arises when a medication is only available as a brand and thus only one pharmaceutical company has market share for that product. Commonly the price of the drug will be quite high due to the high costs associated with developing the drug and running it through various animal and clinical trials in order to obtain FDA approval.

Once the patent (which guarantees a brand name drug market exclusivity for a certain number of years) comes to an end, then other drug manufacturers are given the OK to develop their own generic versions of the medication. More than one drug company can develop a generic which helps drive competition and lower costs such that you’re only paying a nominal fee for your monthly refill of lisinopril. 1

However, is it really that simple?

This all sounds fine and dandy, however, one must realize that it takes years to develop a drug and obtain FDA approval, then another several years of patent exclusivity and even more time for other generics to be developed. Thus, a patient can be stuck with only one brand name drug for a life-saving treatment for years and be faced with sky-rocketing costs.

 

Which medicines are usually associated with high copays?

The medications that are currently commonly available as brand only are some medications for diabetes (i.e. Victoza, Trulicity, Novolog), biologic drugs used to treat inflammatory conditions such as multiple sclerosis, rheumatoid arthritis, and Crohn’s disease (i.e. Enbrel, Humira), drugs to treat or prevent HIV (i.e. Truvada, Genvoya), and inhalers for asthma and COPD such as Advair.2 As one can see, most, if not all, of these medications are intended to treat important medical conditions.

What should we do about this situation?

It is an unfortunate reality that many people each day are faced with the difficult decision of either paying a substantial amount for a medication or surrendering the hopes of trying a new therapy for their medical condition that could have a life-altering impact. However, the story does not end here as there have been programs developed to help reduce costs for expensive brand name medications and increase patient access. One such program is copay cards which will be described in more depth in the next blog so read on if you’re interested!

 

Prepared by Lisa Gerogiu PharmD Candidate 2020

Resources:

  1. Co-pay Accumulator Programs. Access to Healthcare: Info to Know. PAN Foundation; 2018 [cited 2019Aug12]. Available from: https://panfoundation.org/files/Info-to-Know_Copay-Accumulators_Web.pdf
  2. Marsh T. The Top 10 Most Expensive Popular Brand-Name Drugs in the U.S. (and How to Save). Data & Insights. GoodRx; 2018 [cited 2019Aug12]. Available from: https://www.goodrx.com/blog/top-10-most-expensive-popular-brand-name-drugs-us-how-to-save/

Kelley-Ross is an independently owned corporation operating 4 pharmacies in Seattle. Kelley-Ross provides a wide range of pharmacy services, including prescription dispensing, compounding, medi-set packaging, compliance packaging, long-term care facility services, consultant pharmacist services, immunizations and a variety of health screenings.

We provide Clinical Community Care. This means that our staff combines expert medication therapy management and clinical skills, with caring, patient centered pharmacy services. By using the triad approach – patient, provider and pharmacist – we can help patients maximize their healthcare resources while achieving optimal health outcomes.

Our high service level and commitment to problem solving has made Kelley-Ross the pharmacy of choice for patients and providers across the Northwest.