We are an increasingly medicated nation. 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.
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.
People have various strategies to address this problem. Increasingly common is the practice of shopping around — checking prices for medications at various pharmacies, because those prices can vary a lot.
Manufacturers help, but there are a few catches
Every year Patient Assistance Programs help millions of patients who would not otherwise be able to afford brand-name medications. While traditionally PAPs offer free or low-cost medicine to patients lacking health insurance or prescription drug coverage, assistance programs offered by pharmaceutical companies include many different models. As the cost of prescription drugs soar, these programs have evolved to include rebates, coupons and co-pay reimbursement – a controversial practice through which drug companies link charitable giving with boosting sales.
The wildly fluctuating out-of-pocket costs of psychiatric prescriptions force many patients to skip treatment. According to data from the Substance Abuse and Mental Health Services Administration (SAMHSA), often newly diagnosed patients are unable to maintain their prescription regime. If more than 64% of patients covered by HMO and PPO plans were taking antidepressants for the first 12 weeks of treatment, within six months the number of patients on medication dropped by more than 15%, according to SAMHSA.
Patient Assistance Programs, or PAPs, provide free or discounted medication to patients who cannot afford them. To qualify for many PAPs, drug companies often set maximum limits on household income and assets. However, there are some programs for people with higher incomes who need expensive medicines.
To find your medication, go to your handy Google search bar and type in “patient assistance program” Abilify or something similar.
Dr. Richard Sagall, president of NeedyMeds, a nonprofit that collects information about prescription assistance and other resources, says drug companies give away billions of dollars of medication through PAPs every year. “Drug companies don’t like to give out that information, so only estimates are available. Generally, we are talking about $5 to $6 billion,” said Sagall.
Who Is Eligible?
Most pharmaceutical companies offer PAPs, many of them hiring outside companies to run the programs.
“Each pharmaceutical company designs its own programs, so all are different. Some help patients as long as they meet the eligibility requirements. Others have cut offs after three, six or nine months,” says Sagall. When patients reach a cut-off, they have to reapply.
Although eligibility criteria and the application process differ from program to program, common requirements include:
- Limited or no prescription drug coverage from private or public sources;
- A demonstrated financial need based on set income and asset limitations;
- Proof of U.S. residence or citizenship;
- W-2 forms, income tax returns and/or bank statements;
- A list of assets;
- A signed doctor’s letter;
- A current prescription;
- Proof that the needed drugs are not covered by health insurance.
Soaring medication costs coupled with high prescription co-pays have led to the creation of other assistance programs – all under a broader PAP umbrella. These include coupons to encourage patients to start a new brand name drug, copay assistance cards, and rebates and reimbursement coupons to cover insurance premiums.
While all ACA insurance plans are required to cover some prescription medication, patients benefit only if the medicine is included in the plan’s drug formulary. We have heard that prices for the same medication can even vary widely from month to month on the same plan. And even with insurance, many patients will still struggle to pay for prescription drugs – especially if a less expensive generic is not available.
Controversy Over PAP Programs
Co-pay assistance programs put expensive brand-name drugs into the hands of patients who would not otherwise be able to afford them. By donating money to co-pay assistance charities, drug companies not only earn tax breaks, but they also boost drug sales. While millions of patients benefit from co-pay assistance programs, the practice is controversial. Critics argue that they inflate healthcare costs by encouraging more patients to take more expensive, brand-name drugs.
While PAP and co-pay programs undeniably bring benefits to millions, some are skeptical that they are anything more than a tax-subsidized marketing tool. Andrew Pollack of The New York Times has written about them, saying, among other things, that “health insurers and some consumer groups say that in many cases, the coupons are just marketing gimmicks that are leading to an overall increase in health care costs. That is because they circumvent the system of higher co-pays on costlier drugs that insurers use to encourage consumers to use less expensive products.”
His article also says that by insulating patients from prescription costs and encouraging broader use of more expensive brand-name drugs, co-payment assistance plans drive up the costs of health care. For example, one drug company reported to its investors that the co-payment card was responsible for doubling the use of its acne drug. A month’s supply of the brand-name medication is nearly 20 times more expensive than its generic equivalent.
For an individual receiving the drug, gratitude is the obvious response. But the cost of the more expensive drug is then carried by others elsewhere in the system — most likely other patients.
“It seems the best strategy for a pharmaceutical company is to price their drug as high as they possibly can and offer that co-pay assistance broadly” to insulate consumers, said Joshua Schimmer, biotechnology analyst at Leerink Swann, told the Times.
The PAP Application Process
Patients may apply directly to the pharmaceutical company program. Depending on the program, applications can vary in complexity. And navigating the websites of various pharmaceutical companies to locate PAP applications can be challenging. However, there are a number of websites – including www.rxassist.org, www.pparx.org. and www.needymeds.org – that act as clearinghouses to help patients search and identify PAPs that work for them.
According to Sagall, the PAP application response time is fairly fast. It can take up to a month to receive approval, and a month to get the medication. Typically, the prescription – anywhere from a 30- to 180-day supply – is sent to the healthcare provider or the patient’s local pharmacy for pick-up. Once the supply runs out, it’s time to apply again.
One note: People on federally funded health plans like Medicare and Medicaid are typically not allowed to use patient assistance programs because they violate anti-kickback regulations. Here’s an in-depth Reuters piece about usage of PAP programs.
How Much Do Psychiatric Meds Cost for Those Who are not on PAPs?
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.
Some of the most common medications are Xanax, Zoloft, Celexa, Prozac, Ativan, Desyrel, Lexapro, Cymbalta, Valium, Wellbutrin and Effexor. The volume of prescriptions for these and other psychiatric medications can be seen on the PsychCentral site.
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.
ClearHealthCosts offers seven strategies that consumers can follow to save on psychiatric medications. As in all our advice, your mileage may vary — so check to be sure that these handy strategies definitely apply to you.
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.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. There are a million other discount cards out there too. Do your homework, though …
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.
This is the fourth piece in our mental health series. The series, in its entirety, is outlined here.