Patients face insurance restrictions on medications in the form of quantity limits, step therapy, prior authorizations and refill-too-soon limits.
The cost of medication continues to be a political football — and with good reason. Since 2014, the list price for all brand-name and generic medications has increased by more than 33%, and the 20 most-expensive drugs each has a list price of at least $28,000.
"But these high-price-tag drugs for relatively rare conditions don't explain the struggle that so many Americans face in affording their prescriptions," according to a report from GoodRx. "For most Americans, the struggle with affordable medications isn't over the ones that cost thousands of dollars. It's about affording routine drugs for chronic conditions and finding that their insurance doesn't cover what it used to. In other words, Americans are paying more out of pocket."
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An analysis of formulary data from Medicare Part D insurance plans revealed three concerning trends for consumers:
Insurance plans are covering fewer drugs. On average, the share of drugs covered dropped by 18% from 2010 to 2021. Compared to 2010, when an average plan covered 73% of prescribed drugs, in 2021 the average part D plan covered just 55% of prescribed drugs. Mandates for commercial insurance plan coverage vary from state to state, so it's likely that commercial plans have seen an even steeper decrease.
In a GoodRx survey of more than 1,000 patients, 15% noted that one or more of their prescriptions had been dropped from coverage in the past year, and 26% said they take one or more medications that aren't covered by insurance. Patients who can't afford the out-of-pocket price may abandon their prescription completely. This has dire long-term consequences for both the patient and the health care system as a whole.
Insurance for covered drugs is getting more restrictive. As pharmacy benefit managers design formularies and decide on which drugs to add and remove, they also add restrictions to drugs they cover. Research suggests that this can affect physicians' ability to care for their patients, which can end up delaying patient care and increasing overall out-of-pocket costs.
Patients face insurance restrictions on medications in the form of quantity limits, step therapy, prior authorizations and refill-too-soon limits. These restrictions allow insurers to evaluate the medical necessity for a patient's prescribed medication and require them to jump through hoops to receive coverage for their medication.
The patient's share of health care costs is rising. In the last few years, high-deductible health plans have become more common and copayments have risen, leaving Americans to pick up more of the tab for their health care costs. According to the National Center for Health Statistics, from 2007 to 2018, the share of covered workers with a high-deductible plan increased from 15% to 45%.
"All of this leads to sicker patients and higher health care expenses for the country as a whole," the report concluded. "Reducing out-of-pocket costs for patients is good for the country. Lower health care expenses lead to a greater likelihood that patients will take their medications. This prevents poor health outcomes and the development of additional health conditions, and it can even lower insurance costs overall."
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Alan Goforth
Alan Goforth is a freelance writer in suburban Kansas City. In addition to freelancing for several publications, he has written a dozen books about sports and other topics.
