Health insurers cover fewer drugs and make them harder to get – NPR

When it comes to prescription drugs, insurance coverage is different than it used to be.

Insurers’ formulary lists of drugs are shrinking: In 2010, the average Medicare formulary covered about three-quarters of all drugs approved by the Food and Drug Administration. According to a new study from GoodRxa website that helps patients find discounts on prescription drugs. Now, that number is a little more than half.

The GoodRx report is called “The Big Pinch” because it reveals how patients are caught in a bind between drug companies’ high drug prices and health insurers’ limited drug coverage. GoodRx is an NPR funder.

“I think people talk too much about the cost of prescription drugs. We scream about how expensive prescription drugs are.” Tori Marsh, Director of Research at GoodRx“But it’s not poor reporting we’re talking about.”

Marsh said private insurance likely covers even fewer drugs than Medicare because it isn’t bound by the same federal coverage mandates as Medicare.

Additionally, the report found that patients face higher hurdles to getting drugs covered by insurance than they did 14 years ago.

Half of the drugs covered by insurance companies meet the following criteria:Pre-approvalrequiring insurance companies to take the extra step of explaining why they wrote a prescription. This step could create delays and make it harder for patients to get the medication their doctors prescribed. Or it could lead to people not following through on their prescriptions at all.

Insurance companies are trading patients’ access to medicines for lower prices.

Still, limited prescriptions and access restrictions serve business purposes, Jeromy Barich, a health economist at Johns Hopkins UniversityThey give a negotiating advantage to the department within health insurance called the “pharmacy benefit manager” that is responsible for managing pharmacy benefits.

“Their way of fighting back against rising prices and rising spending is to negotiate very hard with the drug companies,” Ballreich said.

For example, insurers may reject a drug company’s offer, but if the company lowers its price or increases its rebates, they will make the drug their preferred choice without prior approval.

Negotiated prices and discounts are not typically passed on directly to consumers as lower out-of-pocket costs, but they can ease pressure on insurance premiums.

The Pharmaceutical Care Management Association, a trade group for pharmacy benefit managers, disputed GoodRx’s report.

“PBMs encourage and help employers design pharmacy benefits that meet the unique needs of their patient populations,” said PCMA spokesman Greg Lopez. “PBMs have a proven track record of improving access to affordable medicines for payers and patients.”

Pharmaceutical companies They criticized PBMs for not properly allocating discounts. Receive it with the patient.

If you are buying insurance, make sure it covers the medicines you need.

GoodRx said its prescription drug list was at its smallest before 2020, but has stabilized somewhat in recent times.

“It’s encouraging that things aren’t getting worse,” GoodRx’s Marsh says, “but I’d like to see this graph move in the opposite direction, with more drugs being covered and fewer drugs being restricted.”

But so far, there has been no expansion of drug coverage in any of the years she has looked at.

If consumers want a more generous plan, they’ll have to shop around, even if it means paying higher monthly premiums, Ballreich said, but most people just want low premiums.

“Choosing health insurance is incredibly difficult,” he says. “I have a PhD in this field.”