As the Patient Protection and Affordable Care Act is phased in, Americans may find they save money on prescription drugs if they don’t use insurance to pay for them.
Just as consumers learned to ask for generic drugs rather than their brand-name counterparts several years ago, they should also find out how much a generic prescription would cost without insurance. Many pharmacies, including Walgreens, automatically fill prescriptions with generics unless otherwise indicated by the doctor or patient.
Sen. Jim Wilson, D-Tahlequah, said the cost for a prescription antibiotic or pain medication is sometimes less than the lowest insurance co-payment.
“For instance, if I’m in Oklahoma City and have an infection or cold for which I’ve been prescribed an antibiotic, when the pharmacist asks if I have insurance, I say ‘no,’” said Wilson. “The reason for this is, rather than paying my $20 co-payment, I pay the actual cost for the prescription, which say, for instance is $6. Generic antiobiotics and pain medications are very inexpensive.”
Wilson said “pharmacy benefit managers,” which are companies hired by larger insurance companies, control the pharmaceutical market through contractual agreements with pharmacies.
“They tell the pharmacies what they’re going to buy and how much they’re going to charge for it, if the pharmacy wants to be able to make claims with that company,” said Wilson. “They also require the pharmacies to collect the full co-payment for a prescription. If a prescription retails at $6, and the patient’s co-payment is $20, the pharmacy will collect the $20. Pharmacists are some of the most respected people in any community, but there’s not enough transparency. If the insurance company can overcharge you by $14, they can save money.”
Most large insurance companies providing prescription coverage have three levels of co-payments. For instance, Blue Cross and Blue Shield of Alabama has a $15 per-prescription co-payment for generic drugs, a $55 per-prescription co-payment for preferred brand-name drugs, and a $75 per-prescription co-payment for non-preferred brand-name drugs. A person covered under BCBSA would pay a $15 co-payment for a hydrocodone/ibuprofen prescription, but would have a $75 co-payment for Vicoprofen, the non-preferred brand-name of the same drug. Generic Valium, or diazepam, would run a $15 co-pay for 60 5-milligram pills, but only $4.39 without the insurance.
According to a July report by the Kaiser Family Foundation, 16 states have enacted legislation imposing a monthly limit on the number of brand-name drugs Medicaid recipients can receive; seven states have either enacted caps or tightened them over the past two years. Oklahoma is on that list, along with Illinois, Arkansas, Alabama, Mississippi, California, Kansas, Kentucky, Louisiana, Main, North Carolina, South Carolina, Tennessee, Texas, Utah and West Virginia. Illinois Medicaid recipients are limited to four name-brand prescription drugs; Mississippi has a limit of two; and Arkansas, six a month. Alabama limits its Medicaid patients to four name-brand drugs per month.
Jeff Sanders, a local registered pharmacist, has been practicing for over 20 years. He’s not aware of any name-brand prescription drugs that will be limited or affected under PPACA.
“The flexible spending accounts may change,” he said. “I know there was some discussion of that early on in the legislation.”
Under PPACA, those whose prescription medications are covered by employer-provided health care plans under flexible spending accounts, health savings accounts or reimbursement arrangements can expect a few changes when it comes to claiming over-the-counter medications on their taxes. As of Jan. 1, PPACA requires OTC medicines, except insulin, to be prescribed by a doctor – if they are to be claimed under cafeteria accounts at tax time.
Some people who are prescribed vitamins or medication to control diet may be concerned they will no longer be covered.
“As far as prescription diet medicines are concerned, I have no idea how they will be impacted,” said Sanders. “I don’t they will be at all under PPACA, but individual insurance companies might make changes that would affect that. Overall, I have not seen anything [under PPACA] that will have any kind of major affect [on the way patients receive prescriptions]. But the depth of the act is so great, it’s just too soon to tell.”
According to Wilson, Oklahoma’s law addressing brand-name drugs differs greatly from those in other states.
“The law we passed allowed the Oklahoma Health Care Authority to purchase generic drugs,” said Wilson. “I believe it may have been specific to certain mental health drugs, as the name-brands for those are very expensive, but I’m not sure. Of course, the vendors want us to buy all name-brand drugs. They’d actually come to committee meetings talking about the supposed differences in their name-brand drugs and the generics, but a generic, by definition, is the same thing.”
Sanders believes generic drugs may be prescribed more frequently under PPACA, but said that given the standards regulating those medications, it may be a good thing.
“I think, as a whole, our country has gotten better at accepting generic products,” said Sanders. “We’re seeing fewer problems with most generics, as they have to fall within [the same] FDA guidelines [as name-brand medications]. I don’t think we’re going to have any issue with that, other than we’ll see higher usage and a higher prescription rate for generics.”
Sanders pointed out that generics prescribed in the U.S. must be made in the U.S., not imported from other countries. He also believes the cost benefit of prescribing generics may prove a good move for consumers.
“From a consumer’s point of view, I’m for saving money wherever we can, as long as the safety and effectiveness [of the generic drug] matches what a name-brand treatment would be,” he said.
Wilson said the restriction doesn’t help control costs, and is another way insurance companies benefit from consumers.
“Two or three things are going on that are screwing the people,” said Wilson. “First of all, we’re not allowed to import drugs; we can [import them] through the Veterans Administration, which gets some the medicines I take from India. In [the European Union] they transfer medications back and forth, tailoring the language on the label to the country it’s going to. It’s all about profit motive.”
Wilson said fraud prevention is lacking in the health industry, and hopes PPACA will address that issue.
To see the complete version of this article, subscribe to the Daily Press e-edition by following the link below.
Click here to get the entire Tahlequah Daily Press delivered every day to your home or office.
Click here to get a free trial or to subscribe to the Tahlequah Daily Press electronic edition. It's the ENTIRE newspaper (without the paper) for your computer, iPad or e-reader.