SUMMARY: Patients who are uninsured or whose prescription coverage is accompanied by crippling out-of-pocket costs often skip prescriptions or forego treatment altogether. The Affordable Care Act (ACA) requires all insurance plans to cover medications, yet not all prescription plans are created equal. The ACA also sets caps on the amount of money patients may pay out of pocket for health expenses – including prescriptions – but consumers still need to educate themselves about the best prices available for the drugs they need, as well as discount offers and assistance programs. Clearhealthcosts looks at options consumers may choose to bring down the cost of behavioural drugs – including prescription assistance programs, coupons, and pharmacy discount cards.
Fourth in our 6-part series on mental health
When it comes to behavioral healthcare, we are increasingly a medicated nation. In the first decade of the millennium, prescription fills for mental health medication nearly doubled.
The Affordable Care Act requires all health plans available through state marketplaces to offer prescription drugs coverage. It also limits expenditures consumers are required to pay in out-of-pocket costs for all health-related expenses This includes medication. While the limit will be adjusted annually for inflation, the 2014 cap for individuals is $6,350; for families it is $12,700. These caps are an improvement for those who may have been uninsured, but they still place expensive medications beyond the means of many patients.
Between 1996 and 2010, prescription mental health medication fills rose from 150.3 million to 396.7 million. More than half of these prescriptions (207.9 million) were for antidepressants. In fact, between 2008 and 2010, prescriptions for antidepressants rose by more than 20 million. Prices for these medications fluctuate wildly. According to Consumer Reports Best Buy Drugs, retail prices for commonly prescribed antidepressants range from about $21 to more than $1,000 a month. The report also includes a list of common antidepressants, lists the average cost of a monthly prescription, and identifies whether a generic is available.
For those who require drugs to treat depression, anxiety, bipolar disorder or schizophrenia, medication is often a high percentage of their mental health expenses. A study looking at what consumers paid out of pocket for mental health services shows patients cover about a third of these expenditures – two-thirds of which were spent on medications.
Under existing health insurance plans and those available through state marketplaces, prescription coverage varies. Through some insurance plans, patients must pay a set percentage of the drug’s cost; others require a co-pay that corresponds to the plan’s formularies, or preferred drug lists. Prescription drug plans differ from state to state, and from insurance plan to insurance plan. Each state sets its own formulary – the list of medicines that are covered by insurance. Many formularies have levels, or tiers – the first tier including the medications that cost the least. With each tier, the amount the patient must cover rises. Each insurance company also has its own formulary for the different plans it offers.
According to Dr. John Grohol, founder of PsychCentral, medications are the most painful cost to consumers. One of the many community forums on his website is dedicated to insurance and finances, through which consumers appeal to each other for advice and share information.
“Medications are challenging. There are still many name-brand medications. Although insurance might be picking up a lot of the cost, there’s a large co-pay, or the insurance company will pay for the generic and you need the name brand, or it’s not on their formulary,” said Grohol. “When there’s a generic available, it doesn’t seem to make a difference to most patients who have to switch.”
Some of the most common medications are Xanax, Celexa, Zoloft, Ativan, Prozac, Lexapro, Desyrel, Cymbalta, Valium, Seroquel, Paxil, Effexor, Wellbutrin, Risperdal, Abilify, Vyvanse, Buspar, Zyprexa and Concerta. The volume of prescriptions can be seen in the chart above on the PsychCentral site. How much do they cost? Prices can vary greatly.
Clearhealthcosts offers seven strategies that consumers can follow to save on psychiatric medications. And watch for Part Five in this series, which focuses on Prescription Assistance Programs.
1) Compare costs at local pharmacies or at large discount stores: Prices for medication can vary greatly from pharmacy to pharmacy, and some offer discount cards, which carry savings of 10 to 25%. Large discount stores, such as Target and Wal-Mart, sell a 30-day supply of many generic drugs for $4.00. And Costco has a Member Prescription Program offering discounts on many prescription drugs. One great resource: here’s one of our blog posts with links to sites telling what pharmacies actually pay for medications. Online sites such as GoodRx.com are useful tools for consumers to use to compare drug prices. A quick search for New York City rates for Seroquel, an antipsychotic drug used to treat bipolar disorder, found rates for the generic varying from $29 at Kmart to $208 at RiteAid – both of which required coupons that can be downloaded from the website. (We have heard frequently that coupons and discount cards do not always work at the named pharmacies, though.)
2) Switch to a generic: For those who pay a flat co-pay for drugs, the co-pay is lower for generics. Just as a brand-name drug is about three times the cost of its generic, the co-pay for brand-names is three times more. For example, if the plan’s co-pay is $5 to $15 for the generic drug, the brand-name will cost $15 to $35. And if prescription coverage is based on a percentage of the full cost of the drug, then the savings with a generic can be even greater. But — don’t always assume that a generic is cheaper, or that generic prices are uniform to all providers.
3) Stick to the formulary: Drugs that are on an insurance plan’s formulary usually cost less than drugs that are not. When getting a new prescription, it is worth it to ask your doctor or pharmacist if the medication is covered on your plan’s formulary. For more information, see Consumer Reports.Formularies are subject to change, and drugs can be added or excluded. If you need a drug that is not on your formulary, your doctor can ask your health plan to approve the drug. This process is called prior authorization. If your health plan denies the request, you can file an appeal.
4) Shop online: Online shopping is handy for patients who have chronic conditions and limited mobility, as the medications are mailed directly to them. Cost-savings vary, depending on the prescription, but they can sell for 35% or more off the regular price. When shopping online, look for the “VIPPS” seal – which stands for Verifed Internet Pharmacy Practice Site. (WebMD has a list of signs that can help consumers ensure an online website is trustworthy.) Some well-known VIPPS pharmacy sites are: www.drugstore.com, www.familymeds.com, www.walgreens.com, and www.cvs.com.
5) Look for discount cards and coupons: A non-profit information resource devoted to helping people find affordable medications and reduce health care related costs, www.needymeds.org offers a drug discount card that can be downloaded from their website. While savings vary for prescription medications, they can be as high as 80%. The card, which is accepted at over 63,000 pharmacies, has no registration, no fee, and no income or insurance requirements. NeedyMeds can also help patients find coupons, rebates and more offers of brand name medicine. These offers may be in the form of a printable coupon, rebate, savings card, 7-30 day free trial offer, or free samples.
6) Be cautious about discount cards and coupons; they may not actually deliver the benefits that they promise: Be a smart shopper. You might ask “What does it cost without the discount? And what does it cost with the discount?” Here’s a blog post with a video from a pharmacist telling how it looks from his end when he gets a discount card.
7. Other resources for buying prescriptions can be found on our “Prescriptions” page: It’s here, and it goes into great detail. If you have other tips, let us know at info (at) clearhealthcosts (dot) com.
Next: Patient Assistance Programs
This is the fourth piece in our mental health series. The series, in its entirety, is outlined here.
- Overview of Mental Health Care in the U.S.
- Finding Affordable Psychotherapy
- Five Reasons Why People Self-Pay for Therapy
- Finding Affordable Psychiatric Medications
- Patient Assistance Programs
- Thinking Out of the Box for Therapy