What Is and Isn’t In Patients’ Control

From the GIC Winter 2016 Newsletter pdf format of fybwinter2016.pdf


Last winter, we provided an overview of why prescription drug costs were skyrocketing:  increases in expensive specialty drugs to treat and/or manage chronic diseases, such as multiple sclerosis, rheumatoid arthritis, hemophilia, and an array of cancers; pharmaceutical industry consolidation that drives up costs for generics and brand name drugs; and increased utilization.  According to the state’s Health Policy Commission, Massachusetts prescription drug expenses increased 13% per capita in 2014 and accounted for one-third of the 4.8% increase in total health care costs.  The ability to tackle rising drug costs continues to be bleak:

  • Introduction of new specialty drugs that have a wide audience of potential users: additional expensive Hepatitis C drugs, cholesterol reducing drugs that cost over $14,000 per prescription, and more oncology drugs.
  • Outrageous increases in existing drug prices.  One example: Turing Pharmaceuticals raised the price of a treatment for a parasitic infection from $13.50 to $700 per pill.
  • Tax inversions where a U.S. pharmaceutical company purchases a non-U.S. firm to avoid paying U.S. taxes.  Example: Pfizer’s pursuit of merging with Allergan, an Ireland-based pharmaceutical company is expected to meet financial goals in part by raising prices, according to a November 23 Boston’s Globe Stat News article.

Median board of director salaries (average of five hours work per week) have increased to $258,000, according to a December 2, 2015 Boston Globe article. 

The pharmaceutical companies claim that high costs are needed to cover research and development.  However,

  • Most transformative drugs derive from publicly-funded research in academic medical centers (Kesselheim & Avorn, Health Affairs 2015).
  • Large pharma companies spend less than 20% of revenues on R&D …and only 5-10% on truly innovative discoveries (Avorn NEJM 2015). Marketing costs are much higher than research costs.

Most of us won’t be able to tackle the root causes of rising drug costs.  However, others may begin evaluating options as drug costs sap needed funds for education, public safety, public health, local aid, transportation, and more. Some of these highly-charged issues include whether or not Medicare should be allowed to negotiate drug prices and patent law reform.

Here are steps you can take to lower your own prescription drug out-of-pocket costs:

  • Bring your plan’s prescription drug formulary with you to doctor visits so you can discuss which tier your prescriptions fall under to see whether there are lower cost alternatives available.  Abbreviated drug formularies that show you alternatives to Tier 3 copay drugs and drugs subject to prior authorization or step therapy are posted on the GIC section of your plan’s website.  (Abbreviated formularies are not available for many GIC Medicare plans.) For members of the employee/Non-Medicare UniCare State Indemnity Plans – keep in mind that some drugs are subject to prior authorization, so be sure to print the new January 2016 formulary and bring it to any doctor visits.  CVS/caremark mailed these out mid-December.
  • Do not ask for a certain prescription drug just because it looked appealing in an advertisement. 
  • Use Mail Order:  If you are taking prescription drugs for a long-term condition, such as asthma, high blood pressure, allergies, or high cholesterol, switch your prescription from a retail pharmacy to mail order.  It can save you money: $5-$30 for three months of medication, depending on the tier.  Once you begin mail order, you can conveniently order refills by phone or online.  Some plans, including the CVS/caremark and SilverScript plans for UniCare State Indemnity Plan members offer mail order copays for maintenance medications at certain retail pharmacies.  Contact your plan for details.
  • Use Specialty Drug Pharmacies Required by your Plan:  If you are prescribed injected or infused specialty drugs, you may be required to use a specialty pharmacy that can provide you with 24-hour clinical support, education, and side effect management.  Medications are delivered to your home or to your doctor’s office.

This information provided by the Group Insurance Commission.