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We estimated the potential out-of-pocket cost savings for individuals based on their health insurance type in Of all prescription fills, 5. This economic evaluation used the Medical Expenditure Panel Survey MEPS , a publicly available, nationally representative survey of individuals and families. We focused on tablets and capsules in and pill quantities and identified generic drugs for the analysis eAppendix in Supplement 1. To account for potential differences in drug costs from to , we adjusted out-of-pocket costs in MEPS using the drug-specific percentage change in the National Average Drug Acquisition Cost. Data were weighted to account for the complex survey design. Analyses were performed using R software, version 4. No cost savings were observed among patients with Medicaid insurance; percentage of filled prescriptions with savings varied by health insurance: Medicare, 5. Among fills with cost savings, A sample of generic drugs with savings is presented in the Table. This economic evaluation found that patients could have spent less on Savings varied substantially by health insurance type, with uninsured patients achieving the greatest benefit. Limitations of our study include its cross-sectional nature. Our analysis was limited to MCCPDC mail-order prescriptions; we did not evaluate the potential cost savings of in-person pickup. Promoting transparent cost-plus pharmacy models, such as MCCPDC, can reduce out-of-pocket costs for a specific subset of patients. Published: June 14, Corresponding Author: Ethan B. Author Contributions: Dr Kouzy had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Lalani and Ludmir contributed equally as senior authors. Critical review of the manuscript for important intellectual content: All authors. Conflict of Interest Disclosures: None reported. Data Sharing Statement: See Supplement 2. We also gratefully acknowledge mentorship from the late Cullen M. Taniguchi, MD, PhD. None of the individuals were compensated for their contributions. Download PDF Comment. View Large Download. Supplement 1. Generic Drugs Analyzed. Supplement 2. Data Sharing Statement. Accessed April 30, Updated December 26, Accessed September 27, Comparison of spending on common generic drugs by Medicare vs Costco members. Cross-sectional analysis of out-of-pocket payments for commonly prescribed generic medications versus discount card pricing. Availability and cost of expensive and common generic prescription drugs: a cross-sectional analysis of direct-to-consumer pharmacies. Published online February 6, Select Your Interests. Save Preferences. Privacy Policy Terms of Use. This Issue. Views 10, Citations 0. View Metrics. X Facebook More LinkedIn. Research Letter. June 14, Ludmir, MD 1,4,5. Back to top Article Information. Access your subscriptions. Access through your institution. Add or change institution. Rent article Rent this article from DeepDyve. Sign in to access free PDF. Save your search. Customize your interests. Privacy Policy. Make a comment.
Strategies to Help Patients Navigate High Prescription Drug Costs
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Published online October 21, Importance In the US, many patients struggle to afford prescription drugs, leading to adverse health outcomes. To improve cost-related medication nonadherence, prescribers and clinical staff must understand how to assist patients in overcoming high prescription drug costs. Observations We reviewed the benefits and limitations of 7 strategies to help patients afford prescription drugs: co-payment cards, patient assistance programs, pharmacy coupons, direct-to-consumer pharmacies, public assistance programs, international online pharmacies, and real-time prescription benefit tools. For example, co-payment cards can lower out-of-pocket costs for privately insured patients taking brand-name prescription drugs. For uninsured individuals or those with public insurance like Medicare Part D who meet financial eligibility criteria, patient assistance or public assistance programs may be available. All patients, regardless of health insurance, can forgo insurance and purchase drugs directly using pharmacy coupons or direct-to-consumer pharmacies, which sometimes offer lower prices for generic drugs compared to insurance. For insured patients, such purchases do not count toward insurance deductibles or annual out-of-pocket maximums. Online international pharmacies provide a last resort for patients in need of brand-name drugs who lack affordable domestic options. Increasingly, prescribers can use real-time prescription drug benefit tools to estimate patient out-of-pocket costs and identify alternative lower-cost treatments for insured patients, but these tools can be inaccurate or incomplete. Conclusions and Relevance The current patchwork of strategies to help patients manage high prescription drug costs highlights the structural and policy challenges within the US prescription drug market that impede affordable access for some patients. While these strategies provide tangible solutions for clinicians to help patients access medically appropriate but costly medications, they do not address the root causes of high drug prices. In the US, high prescription drug costs are a major barrier to the optimal treatment of many health conditions. About 3 in 10 adults struggle to afford their medicines, and rates are even higher among patients with multiple chronic conditions, those with low socioeconomic status, and those who identify as Black or Latino. There are several reasons why prescription drugs cost substantially more in the US than in other high-income countries. Most insured patients have some degree of prescription drug coverage to protect them from high drug prices. But even those with insurance can be exposed to high costs. Clinicians often lack the time or knowledge to help patients overcome cost-related barriers to accessing medically necessary prescription drugs, 14 and several of these strategies do not require the direct involvement of prescribing clinicians. However, clinicians still play a crucial role in educating patients about available options. Two case scenarios applying the algorithm of prescription drug affordability tools are described in the Box. A year-old female patient with a history of hypertension and type 2 diabetes is newly diagnosed with atrial fibrillation. After a discussion about stroke risk, her clinician recommends anticoagulation with a direct oral anticoagulant. She is prescribed apixaban Eliquis. Physician and patient discuss dabigatran, a generic therapeutic alternative. The patient is not eligible for the Medicare Extra Help program or her state Medicaid program. The patient considers applying for a patient assistance program through the manufacturer or a nonprofit organization if she meets financial eligibility criteria. It will take a few weeks to complete the entire process and receive a final decision. The patient uses PharmacyChecker to check apixaban prices at international online pharmacies. The patient chooses this option, knowing this payment will not count toward her insurance annual maximum. During the annual Medicare open enrollment period, the patient will compare Part D prescription drug benefit plans to see if apixaban would have lower out-of-pocket costs through a different plan. A year-old male patient with obesity, tobacco use disorder, and chronic kidney disease presents to a clinic reporting erectile dysfunction. This negatively impacts his relationship with his partner. He is prescribed generic tadalafil. The patient is enrolled in a high-deductible health plan through his employer. The patient lives close to a few pharmacies and prefers to pick up the prescription in person instead of receiving it in the mail. The patient and clinician search for a pharmacy coupon using GoodRx. The patient chooses this option, knowing this payment will not count toward his insurance deductible. The clinician sends the prescription to the chosen pharmacy and the patient is able to pick it up the same day after showing his pharmacy coupon. In the future, the patient could shop for the medication at direct-to-consumer pharmacies, particularly because pharmacy coupon prices vary over time. The existence of a variety of strategies to lower prescription drug costs for patients highlights the complex, opaque, and systemic challenges within the US pharmaceutical distribution and pricing system, and the need for reform. Manufacturers of brand-name drugs frequently offer co-payment cards to offset patient out-of-pocket costs for prescription drugs. Co-payment cards are readily available from manufacturer websites and require minimal patient information to access but can only be used by patients with private health insurance. Patients with public insurance, such as Medicare or Medicaid, are ineligible because these cards violate the federal antikickback statute. Although co-payment cards typically last for 12 months, they can be renewed if the manufacturer permits it. Co-payment cards can be useful for helping privately insured patients afford necessary brand-name medications, but on a population level, they also incentivize the use of more expensive medications. Some brand-name drug manufacturers offer patient assistance programs to offset the out-of-pocket costs of expensive brand-name drugs for uninsured or underinsured individuals. These programs are typically restricted to patients who meet specific needs-based eligibility criteria. Patient assistance programs are available across public and private insurance, but options for uninsured patients may be more limited, particularly when programs are offered by nonprofit organizations, such as the HealthWell Foundation and the Patient Access Network Foundation. Due to their heterogeneity and lack of transparency, there is limited rigorous research on the clinical benefits and cost-effectiveness of patient assistance programs. When insurance plans charge substantial out-of-pocket costs or do not include particular medications on their formularies, some patients may benefit from purchasing the prescription drug directly from pharmacies without insurance. Ordinarily, retail pharmacies charge high prices for cash-paying customers, but several organizations eg, GoodRx, SingleCare, WellRx, NeedyMeds offer coupons through which patients can access discounted prices negotiated by pharmacy benefit managers on behalf of insurers. These coupons are typically available online or through smartphone applications. Coupon prices for a prescription drug can change frequently and vary by retail pharmacy and zip code. These coupons are available to all patients regardless of insurance status. They can be particularly helpful for uninsured patients and those with high-deductible health plans who take generic medications. The coupons can also be useful for drugs that are frequently subject to coverage restrictions, such as generic medications for erectile dysfunction eg, sildenafil, tadalafil , hair loss eg, low-dose finasteride , and weight loss eg, topiramate, phentermine. Although coupons are available for some brand-name drugs, discounted prices can still be high. For patients taking multiple medications, it may be more advantageous to pay higher prices in the short term if possible to maximize insurance benefits later in the year. Pharmacy coupons also require patients and clinicians to shop around for the lowest prices; this may require patients who take multiple medications to use multiple pharmacies, which can be time-consuming and confusing. Direct-to-consumer pharmacies sell a selection of drugs at transparent prices if patients purchase them without insurance. These pharmacies are new entrants in the US prescription drug market, and they provide patients with the option to purchase a range of commonly used generic drugs at prices that may be lower than their insurance-required out-of-pocket costs. Some big-box chain retailers eg, Walmart, Costco have direct-to-consumer pharmacy programs with in-person pickup and mail-order options. Other direct-to-consumer pharmacies eg, Amazon Pharmacy, Health Warehouse are exclusively online. The Mark Cuban Cost Plus Drug Company primarily sells medications online but also partners with independent grocery store pharmacies for in-person pickup. Table 3 summarizes the key features of 5 popular direct-to-consumer pharmacies. For certain drugs, direct-to-consumer pharmacies can lead to substantial savings. Similar to pharmacy coupons, direct-to-consumer pharmacies are most helpful for uninsured individuals and those with high-deductible or high co-payment health plans who use generic medications or drugs not covered by insurance. For most insured patients, it is more economical to purchase generic drugs using health insurance than from direct-to-consumer pharmacies. Several federal, state, and local programs help patients afford prescription drugs. The largest such program is Medicaid, which provided prescription drug coverage to more than 75 million individuals in the US as of March Patients with Medicare Part D coverage who meet certain financial eligibility criteria pay lower out-of-pocket costs due to government-funded low-income subsidies, known as the Extra Help program. Local programs can also help patients afford prescription drugs. Prices for brand-name drugs in the US are 2 to 3 times higher than prices for the same drugs in other countries, 42 leading some patients in the US to try to import these drugs. It is illegal to import a drug that is unapproved in the US, but the FDA permits patients to purchase FDA-approved drugs internationally as long as they are for personal use, for treatment of a serious condition, and the quantity does not exceed a 3-month supply. Several states are attempting to enact broader drug importation for their residents. In January , the FDA authorized a Canadian drug importation program designed by Florida; the state plans to import up to 17 brand-name prescription drugs to treat conditions including HIV, heart failure, and prostate cancer. One major hurdle to medication affordability is that patients and prescribers lack information about coverage and out-of-pocket cost requirements. However, these tools can lack adequate patient pharmacy benefit data to generate notifications, produce inaccurate cost estimates, and provide insufficient recommendations about alternative treatment options. This may be changing, as one of the largest pharmacy benefit managers, Optum Rx, launched a tool in January that automatically offers patients the lowest price available with pharmacy coupons. The drug affordability tools described above can provide patients with financial relief in accessing clinically necessary prescription drugs, but they also invoke legal and financial considerations. After multiple investigations, pharmaceutical companies have paid hundreds of millions of dollars in settlements to the US Department of Justice to resolve antikickback statute violations. These strategies can raise overall health spending by lowering the barriers to prescribing expensive brand-name prescription drugs. For example, the use of co-payment cards and patient assistance programs likely increases the use of expensive brand-name drugs, even when less expensive or more cost-effective alternatives are available. Drug manufacturers are often willing to provide rebates in exchange for preferred formulary positions that result in improved patient access. However, they may be less willing to provide rebates if they can use co-payment cards to make their prescription drugs accessible to patients, even without preferred formulary status. To minimize this, prescribers should consider more affordable therapeutic alternatives before recommending that patients use co-payment cards or patient assistance programs Figure. The availability of generics can be determined using prescription drug compendia, such as Micromedex or Lexicomp. Real-time prescription drug benefit tools can help clinicians select a medication covered by insurance, but prescribers must be cautious of incomplete or inaccurate information and lower-cost options outside of health insurance. In cases where insurers prefer an alternative medication with lower out-of-pocket costs for a patient, prescribers should communicate with patients about these options and facilitate informed, shared decision-making about which medication to select. For brand-name drugs, patients with private health insurance should search for a manufacturer co-payment card. If co-payment cards are unavailable or if patients are ineligible eg, Medicare beneficiaries , then patients with financial hardship can apply for need-based financial assistance from drug manufacturers, nonprofit organizations, or public assistance programs. Patients who are ineligible for need-based financial assistance should evaluate drug prices at reputable international online pharmacies to determine if personal importation is an affordable option. For patients with difficulty affording or accessing generic drugs due to high out-of-pocket costs or insurance coverage restrictions, clinical teams should investigate using pharmacy coupons or direct-to-consumer pharmacies and forgoing health insurance altogether. Considering factors such as the cost of the drug, urgency for receiving the medication, and existing store or service memberships can be helpful in selecting the best option for the patient. If a pharmacy coupon is selected, medical staff can facilitate this process by sharing a coupon that matches the prescription drug name, strength, and quantity. The patchwork of prescription drug affordability strategies outlined in this review illustrates the complex, fragmented, and inefficient prescription drug delivery and reimbursement system in the US. The need for clinicians and patients to supplement prescription drug coverage with additional affordability strategies underscores the urgency for system-wide policy reforms, such as expanding Medicare price negotiation and out-of-pocket limits introduced by the Inflation Reduction Act to all patients in the US. In the meantime, it is important for clinicians to understand the array of strategies that are currently available to help patients navigate the high costs of prescription drugs. Corresponding Author: Hussain S. Published Online: October 21, Author Contributions: Dr Lalani had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. In addition, Dr Kesselheim reported serving as an expert witness in a case on behalf of a group of state attorneys general and private insurance carriers relating to generic drug pricing, on behalf of a class of plaintiffs against Gilead in a case relating to its tenofovir-containing products, and as an expert with the Federal Trade Commission in the Amgen-Horizon merger case now settled. No other disclosures were reported. View Large Download. Table 1. Table 2. Table 3. Characteristics of 5 Direct-to-Consumer Pharmacies. Podcast Subscribe to Podcast. Public opinion on prescription drugs and their prices. Published August 21, Accessed September 30, The association between medication non-adherence and adverse health outcomes in ageing populations: a systematic review and meta-analysis. Cost-related nonadherence and mortality in patients with chronic disease: a multiyear investigation, National Health Interview Survey, RAND Corporation. Comparing international prescription drug prices. Accessed January 8, The high cost of prescription drugs in the United States: origins and prospects for reform. US Food and Drug Administration. Generic competition and drug prices. Published October 5, Generic drugs in the United States: policies to address pricing and competition. University of Southern California; June 6, Competition and vulnerabilities in the global supply chain for US generic active pharmaceutical ingredients. Pharmacy benefit managers: history, business practices, economics, and policy. The devil in the tiers. Explaining the prescription drug provisions in the Inflation Reduction Act. Published January 24, Accessed November 27, Savings and support info for Rx Eliquis apixaban : safety info. Accessed October 9, Characteristics of copayment offsets for prescription drugs in the United States. Patient assistance programs and the anti-kickback statute: charting a pathway forward. When discounts raise costs: the effect of copay coupons on generic utilization. Accumulators and maximizers: a new front in the battle over drug costs part 2. Health Affairs Forefront. November 18, Accumulators and maximizers: a new front in the battle over drug costs part 1. November 17, Copay accumulator lawsuit comes to an end; will ruling be enforced? MMIT Network. Published February 15, Accessed July 27, Drug company-sponsored patient assistance programs: a viable safety net? Giving a buck or making a buck? Boehringer Ingelheim. Boehringer Ingelheim Cares patient assistance program eligibility. Published January 1, Accessed July 31, Financial eligibility criteria and medication coverage for independent charity patient assistance programs. What is the evidence for pharmaceutical patient assistance programs? Variation in prescription drug prices by retail pharmacy type: a national cross-sectional study. Direct-to-consumer generic drugs: a maverick approach or another exposure of market failures? Comparison of spending on common generic drugs by Medicare vs Costco members. Availability and cost of expensive and common generic prescription drugs: a cross-sectional analysis of direct-to-consumer pharmacies. Blue Shield of California. Accessed October 10, Accessed July 28, Pricing and payment for Medicaid prescription drugs. Published January 23, Social Security Administration. Understanding the extra help with your Medicare prescription drug plan. Help with drug costs. State programs. Get naloxone delivered for free. Prescription drug assistance. International prescription drug price comparisons: estimates using data. Published February 1, Accessed August 1, The international pharmaceutical market as a source of low-cost prescription drugs for U. Personal importation. Published December 7, Centers for Disease Control and Prevention. Drug price comparisons and online pharmacy safety. Accessed January 12, Published January 6, Published Real-time benefit tools for drug prices. Effects of real-time prescription benefit recommendations on patient out-of-pocket costs: a cluster randomized clinical trial. Real-time prescription benefit tools—the promise and peril. Implementation and cost validation of a real-time benefit tool. Accessed September 8, Fraud and abuse laws. Published September 1, Accessed July 14, Patient assistance programs and anti-kickback laws. OIG advisory opinion No. Published April 11, Accessed August 26, New favorable OIG advisory opinion allows patient assistant programs funded by drug manufacturers. Published April 25, Prescription-drug coupons—no such thing as a free lunch. Save Preferences. Privacy Policy Terms of Use. New Online. Views 0. Citations 0. View Metrics. X Facebook More LinkedIn. Special Communication. October 21, Hussain S. Co-Payment Cards. Patient Assistance Programs. Pharmacy Coupons. Direct-to-Consumer Pharmacies. Public Assistance Programs. International Online Pharmacies. Real-Time Prescription Benefit Tools. Approach to Helping Patients Afford Medications. Back to top Article Information. Access your subscriptions. Access through your institution. Add or change institution. Free access to newly published articles. Purchase access. Rent article Rent this article from DeepDyve. Sign in to access free PDF. Save your search. Customize your interests. Create a personal account or sign in to:. Privacy Policy. Make a comment.
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