As we exit 2016, we can only be certain about one fact regarding the future of health care coverage in America: big changes are ahead. Our healthcare was one of the biggest issues in a bitter Presidential campaign, and President-elect Trump has repeatedly said that he plans to replace Obamacare with something else. We’ll see what that something else is soon.
As politicians fought about the best ways to solve America’s health care challenges, we all suffered. Insurance premiums went up and also provided less coverage. Prices for many brand drugs continued their steady march upwards. There was some good news—exciting new treatments, and a bunch of expensive drugs became available as generics—but in general, 2016 was a painful year, and the prognosis for 2017 isn’t much better.
Here’s a recap.
1. More drugs lost insurance coverage.
The two largest prescription insurance companies, Express Scripts and Caremark, dropped coverage for 40 popular drugs in 2016. Most notably, medications like the popular insulin Lantus, and venlafaxine ER (Effexor XR) for depression have been dropped by Caremark. Express Scripts dropped Taltz for psoriasis, and Orencia for rheumatoid arthritis, among others, and Viekira Pak now has only limited coverage. Insurers are also restricting coverage for many of the expensive (but effective) hepatitis C drugs like Zepatier and Olysio, leaving only Sovaldi and Harvoni as options.
Overall, Caremark will be far more restrictive this year, with a total of 130 drugs excluded from coverage. In contrast, Express Scripts will only have 85 drugs excluded in 2017.
New for 2017—Caremark is dropping coverage based on excluding what they call “hyperinflationary drugs” or drugs that have seen a massive increase in cost. Think EpiPen, Alcortin A, and others you may have seen in the news this year.
2. Even more drugs went generic in 2016. Yay!
There is good news! A number of drugs went generic this year, meaning that more expensive brand name medications now have cheaper alternatives. In some instances, filling a generic instead of a brand can mean a difference of hundreds of dollars, whether you’re insured or paying cash. So this is good news for your healthcare wallet!
Here some of the major drugs that got generic alternatives in 2016:
- Gleevec (imatinib), an expensive specialty medication used to treat multiple types of cancer, went generic in February. Although the generic, imatinib, is still expensive, it does offer savings over the brand. This is a big deal—Gleevec has been very effective, and a lower cost generic will make it more accessible.
- Glumetza (metformin ER) is a popular drug used to treat type II diabetes that went generic in February. Glumetza is similar to the other type II diabetes drug Fortamet (also metformin ER), but they differ slightly in how they deliver the drug. You can read more about their similarities and differences here. Also—keep in mind that Glucophage XR has had a less-expensive generic for a few years now, and is still significantly cheaper than Glumetza or Fortamet.
- Enablex (darifenacin ER), for overactive bladder, went generic in March 2016. Although the generic, darifenacin ER, is on the pricey side, it will save consumers hundreds over the brand name.
- Nasonex (mometasone) is a popular corticosteroid used to decrease inflammation in the nose and treat the symptoms of allergies. Nasonex’s generic, mometasone, was approved in March.
- Crestor (rosuvastatin) is a major brand that got a generic alternative in April 2016. Crestor had been dropped by many insurance plans, but with the introduction of a generic alternative, consumers have been able to save big at the pharmacies for this popular statin.
- Epzicom (abacavir/lamivudine) is an antiretroviral used to treat HIV. Its generic, abacavir/lamivudine became available in October, offering huge savings.
- Benicar (olmesartan) is another major brand that became available as a generic drug this year. Benicar is a popular medication used to treat high blood pressure, and its generic, olmesartan (available only in tablet form) offers consumers a pretty substantial discount.
3. Insurance costs are going up.
You may have heard that Obamacare (Affordable Care Act or ACA) plan premiums are expected to climb by about 25% in 2017. Because so many insurance companies dropped out of the exchange markets this year, you can expect to pay an average monthly premium of $302, up from $242. Some companies are also raising rates because the premiums they charged initially were too low to cover the costs they faced. Many of these plans also offer limited coverage, especially for prescription drugs.
You can find more information on changes to ACA plans in 2017 here.
You can also expect to see some price increases and changes in coverage if you have a Medicare plan. More plans that ever (up to 85% in 2017) will have a preferred pharmacy network, meaning they will offer the maximum savings only at certain pharmacies. There is some good news here though—the donut hole is shrinking. You’ll owe a smaller percentage of both brand and generic drug costs while in the donut hole.
You can find more specifics on 2017 Medicare plan changes here, and on GoodRx! In May, Goodrx completed a multi-year effort to analyze Medicare drug pricing and help seniors take control of their prescriptions. Read more about it here, or compare Medicare, cash, and coupon prices on GoodRx here.
Of course, many elements the ACA will likely change in 2017 when President-elect Trump takes office . . .
4. 2016 was the year of outrageous drug prices.
The EpiPen drama exploded in the fall of 2016 as outraged parents encountered insane prices for a life-saving prescription. As you may have heard, Mylan, the makers of EpiPen, have raised prices for the lifesaving drug from about $150 to $600 since 2011. There is good news on the horizon though: Mylan has discussed creating a generic alternative to Epipen, and a less expensive epinephrine auto-injector, Auvi-Q, which should return to the market soon.
Insulin prices also continue to increase, with popular options like Lantus, Humalog, and Novolog increasing by around $150 per carton since 2013. This may hit some of you especially hard with Caremark’s decision not to cover Lantus next year.
Some other sky high drug prices continue to include Daraprim, Sovaldi and other hepatitis C drugs, and treatments for very rare conditions like hereditary angioedema (HAE).
What’s in store for 2017?
As you know, Donald Trump is our new president-elect. There are almost definitely changes in prescription and health care costs, and the future of ACA plans is in question. Stay tuned!
There will be more generics released- especially near the end of the 2017. Though none of these are guaranteed, popular drugs like Viagra (sildenafil) for erectile dysfunction, Truvada (emtricitaboine/tenofovir) for HIV treatment, and the expensive epinephrine auto-injector EpiPen (epinephrine) may see more generic alternatives in 2017.
One thing we can all be sure of—it’ll be more important than ever for Americans to be smart healthcare consumers, and GoodRx will be there to help!
Happy holidays and have a happy, healthy new year!
Americans are clearly unhappy about the rising cost of prescription drugs and healthcare, and the leading 2016 presidential candidates have proposed all sorts of ideas to fix the problem. Here’s a snapshot of what the candidates have said on these important issues.
Where the Major Candidates Agree
It’s hard to imagine Clinton and Trump agreeing on anything, but they actually have some ideas in common. Here’s a summary:
- Both Trump and Clinton advocate importing prescriptions from overseas. Brand-name drugs are significantly more expensive in America than elsewhere throughout the world, as most Americans know. Both candidates propose legalizing the importation of prescriptions from other countries to help reduce the rising cost of brand drugs.(Interesting side fact: Many generics are actually the same price, or even cheaper, in America than they are in many other countries, including Canada.)
- Both Trump and Clinton support allowing Medicare to negotiate prices with drug companies. Most Americans agree that it’s outrageous that Medicare isn’t allowed to negotiate to reduce the cost of the prescriptions Medicare purchases for seniors. (Just for reference, in 2014 that cost was $143 billion). This issue seems to be one that has universal support among candidates.
- Both have called for more transparency in health prices.
- Both want to increase innovation and reduce time-to-market for new prescription drugs.
Where the Candidates Disagree
Donald Trump hasn’t provided many details regarding his plan for healthcare, but he has some specific proposals that would impact healthcare costs and services in this country. Specifically:
- Repeal Obamacare. Trump wants to repeal Obamacare (the Affordable Care Act or ACA) and restore free market principles. He believes the ACA has caused runaway healthcare costs, higher premiums, and fewer choices, among other issues. He has promised to repeal Obamacare on “day one” of his administration.
- Insurance. While anti-Obamacare, he still supports the mandate that everyone be required to have health insurance (and also said no one should be required to have insurance). He wants to change current laws to allow the sale of health insurance across state lines, stating that increased competition will drive down prices. He also wants to allow insurance premiums to be tax-deductible.
- Immigrants. Trump blames illegal immigrants for high prescription prices, saying it costs $11 billion annually to insure them.
Hillary Clinton, by contrast, has posted extensively about her plans to expand Obamacare and tackle the high cost of prescription medications. She was very vocal during the EpiPen price controversy during the summer of 2016 when she demanded an explanation from the manufacturer. Here’s a summary of Clinton’s positions:
- Defend and expand Obamacare & Medicare. Expand the program, and let Americans 55 and older buy into Medicare.
- Costs. Reduce co-pays, deductibles and out of pocket limits, especially for patients with chronic conditions. She proposes a limit of $250/month per person, and says it will help 1 million Americans annually.
- Advertising. Prohibit the pharmaceutical industry from advertising directly to consumers.
- Limits. Require drug companies that get taxpayer support to invest in research, not marketing, and limit “excessive” profits.
- Brand drugs. Clinton has proposed penalties to drug manufacturers who raise drug prices without justification, as well as government intervention to find other manufacturers or solutions when a brand-name drug increases in price.
- Patents. Reduce patent protection for specialty drugs from 12 years to just 7, so Americans can get access to generics quicker. Also prohibit the practice of letting drug companies pay to delay the expiration of drug patents.
- FDA. Clear out the FDA backlog of unapproved drugs.
Both candidates have made claims which appear to be factually inaccurate.
In a March 2016 debate, Trump claimed the government could save “hundreds of billions of dollars in waste” through negotiating prescription drug prices. However, the annual budget for Medicare Part D is less than that amount.
In a January 2016 advertisement, Clinton’s campaign claimed that drug prices have doubled in the last seven years. While brand name drugs have increased in price, generic drug prices have actually dropped significantly. The average increase for all drug purchases, while hard to measure, is likely not double.
What about the other presidential candidates?
Other presidential candidates may be less well known, but they’ve touched on healthcare reform.
Jill Stein (Green Party)
Stein believes strongly in the role of the government to provide quality healthcare for Americans. From her campaign website: “(Jill will) establish an improved ‘Medicare For All’ single-payer public health insurance program to provide everyone with quality healthcare, at huge savings.” Her plan would eliminate co-pays, premiums and deductibles, as well as any limitations whatsoever. Her platform does not indicate how these expanded benefits would be funded. Like Clinton and Trump, she also wants to use bulk purchasing negotiations by the government to reduce the cost of prescriptions.
Gary Johnson (Libertarian Party)
Johnson does not specifically mention drug prices on his campaign website. Typically, libertarian candidates prefer market forces to legislation, so one could presume that he would generally be against new laws or interference with the private market. Gary believes “the government should never regulate prices of private businesses.” While not directly related to prescription drugs, Johnson also advocates legalizing the use of marijuana.
Where does GoodRx stand? What’s the right answer?
The best candidate to tackle high drug prices is . . . nah, we’re not going to go there.
Providing quality, affordable healthcare is a very complicated problem, and it likely requires more than a bunch of campaign promises to solve. The solution requires big changes to the way our system currently works—Congress, insurance companies, employers and, yes, patients will all have to reset expectations.
Regardless of which candidate wins, we’ll continue to do our part to help Americans understand the system and find ways to afford their healthcare.
Americans, get ready for sticker shock at the pharmacy.
In 2017, the nation’s largest insurance companies will likely exclude up to 154 different drugs from coverage. If you’re taking one of these prescriptions, your co-pay is about to go way, way up.
Last year, popular drugs including Viagra and Qsymia were dropped by major insurance plans for 2016. The trend continues this year. Almost 50 popular brand-name and generic drugs will likely no longer be covered by one of the nation’s largest prescription insurance providers.
Who’s removing these drugs? Express Scripts and Caremark, companies that handle pharmacy benefits for more than 200 million Americans, are once again removing drugs from their national preferred formularies. Other pharmacy benefit managers will likely announce similar restrictions in the coming weeks.
What are Express Scripts and Caremark?
Express Scripts and Caremark are companies that administer prescription drug benefits for many health insurance companies and Tricare. While you may have health insurance from Anthem, Aetna or another insurer, your pharmacy benefits are usually handled by these companies or their competitors. They create a formulary—a list of drugs they will cover—in conjunction with employers and health plans.
What does this change mean for you?
The newly excluded drugs fall into a couple major categories:
Several are brand-name drugs that may have a less expensive brand or generic alternative available.
Some drugs work in the same way as similar, cheaper drugs on the market, so only one is preferred by your insurance.
If your benefits are provided by Express Scripts or Caremark, you will pay the full cash price at the pharmacy for these excluded drugs in 2017. (On GoodRx, you can see estimated cash prices in grey next to most discount prices.)
If your coverage is changing, talk to your doctor to see if one of the covered alternatives might work for you. If you can’t switch, use GoodRx to find discounts or find patient assistance programs to help cover the cost. You may also be able to appeal the coverage with your insurance provider, with your doctor’s help.
Which drugs are affected?
Caremark in particular is making some major changes for 2016, which fall under three general categories: “hyperinflation” drugs (drugs that have had recent drastic price increases), new biosimilar alternatives, and stricter restrictions on expensive cancer and hepatitis C medications.
Hyperinflation. Caremark has identified some drugs that have had huge price increases, and excluded a selection that have similar alternatives in the same class of medications. One example is Alcortin A, which saw a 30-fold price hike over the past three years.
Biosimilars. You may have heard news over the past year or so about “biosimilars”—basically, generic medications for some specialty or biologic medications like insulin. (For more background on biosimilars, see our post here.)
Notably, Caremark will no longer cover Lantus, one of the most popular insulin brands.
Caremark is the first provider to restrict brand name drugs like Neupogen or Lantus that have (or will have) biosimilars available next year. They are suggesting Zarxio in place of Neupogen, and Basaglar in place of Lantus.
Expensive specialty medications. Caremark is also breaking ground by being the first provider to restrict coverage on brand name cancer treatments.
How can I make sure I pick a plan that will cover my drug?
Both Express Scripts and Caremark have made some fairly big changes in coverage over the past few years, and the overlap on many of the excluded drugs is shrinking. If you’re trying to choose a new plan, or switch based on coverage of a particular drug, it’s always a good idea to review the latest formularies before deciding.
Below, you can find all of the new removals from both formularies in 2017. For a full list of all excluded drugs and covered alternatives, see the Express Scripts list here and the Caremark list here. If you’re not sure which company provides your pharmacy benefit, contact your insurance.
If you have a choice though, Caremark will be far more restrictive in 2017. They are excluding about 40 new drugs, for a total of around 130. Express Scripts, in contrast, is only restricting 5 new drugs in 2017, for a total of about 85 that they will not cover.
New Exclusions for 2017
Alcortin A (Caremark)
All non-BD pen needles and syringes (Caremark)
butalbital/acetaminophen/caffeine capsules (Caremark)
Carnitor SF (Caremark)
Colchicine (Express Scripts)
Effexor XR (Caremark)
Fioricet capsules (Caremark)
Helixate FS (Caremark)
Kineret (Express Scripts)
Klor-Con packets (Caremark)
Millipred DP (Caremark)
Orencia (Express Scripts)
Proventil HFA (Caremark)
Taltz (Express Scripts)
venlafaxine ER (except tablet) (Caremark)
Ventolin HFA (Caremark)
Zebutal capsules (Caremark)
Zyclara (Express Scripts)
An important note about Medicare and individual plans:
These changes DO NOT apply to Medicare plans; if your Medicare benefit is managed by Express Scripts, you should check your coverage with your pharmacist or online through the Medicare.gov portal.
Some individual private insurance plans managed by Express Scripts or Caremark may also have different coverage. This means different drugs may be covered or excluded on your plan if you have coverage through work, for example. Please get in touch with your insurance provider if you have any questions about your coverage.
Medicare Part D and Advantage plans are meant to help make prescription drugs more affordable for seniors.
Ask any senior about their Medicare coverage, however, and you’ll find out that Medicare coverage is far from perfect. Many prescriptions aren’t covered, there are all sorts of rules and limitations, and then there’s the dreaded “donut hole” coverage gap.
GoodRx has completed a multi-year effort to analyze Medicare drug plans, and has found thousands of opportunities for senior to save.
Today, GoodRx is launching GoodRx For Medicare to help seniors take control of their prescriptions and find savings.
Key features of GoodRx For Medicare include:
- Drug Price Lookup: Instantly look up prescription drug co-pays for any of the 30,000+ Medicare Part D and Advantage plans in America. No need to sign up, register, and completely free to use.
- Find Savings: Many prescriptions can be purchased for less than the typical Medicare co-pay. GoodRx finds savings and shows Medicare consumers when they can actually save more by NOT using their prescription drug coverage.
- Compare Plans: Use GoodRx for Medicare to instantly compare prices for your prescriptions across multiple plans and see which plan is best for you.
- Know Limitations: Just because a drug is covered by a Medicare plan doesn’t mean the plan will make it affordable. Over 44% of prescriptions have coverage limitations which can prevent Medicare consumers from affording their prescriptions. like doctor authorizations, quantity limits and more. GoodRx lets you know about the “fine print” which plans won’t tell you about in advance.
- Create A Prescription Spending Strategy: Worried about the donut hole? Use GoodRx to control your Medicare spending in new ways.
- Find Help For Non-Covered Drug: Many popular drugs are simply not covered by Medicare. GoodRx can provide huge discounts of up to 80% on those prescriptions.
What does this mean for you? If you have Medicare coverage, it still pays to shop around. For the top 20 Medicare plans in America, 66% of prescription drugs can be purchased for less than your typical Medicare co-pay using discounts found on GoodRx.
Search for your prescription now to see your co-pay (and how much you can save): https://www.goodrx.com/medicare
Hidden deep within your health plan is an important document most people never read.
Your “formulary”—the list of drugs your insurance company covers—determines whether you’ll share the cost of your prescription with your insurance company or you’ll be stuck paying a high price at the counter.
This list can change during the plan year—drugs are removed, new drugs are added, restrictions may be added or removed, and coverage levels may change throughout the year. (Changes are the most likely when it’s re-enrollment time.)
Nobody wants to be stuck paying the full cost of their prescription, so you’ll want to be diligent in checking to make sure your current prescriptions are covered by your plan’s formulary. You can usually find it on your health insurer’s website.
GoodRx sat down with Consumer Reports Best Buy Drugs to answer five common questions about how to make sure your prescriptions are covered—and what to do if they’re not.
GoodRx: What if my prescription drug is dropped entirely by my insurance plan?
Best Buy Drugs: If your drug is no longer covered, first ask your doctor about other drugs on your formulary that may be just as effective and safe for your condition. Most plans will offer one or more alternatives to a medication they no longer cover.
If using an alternative isn’t possible, your doctor can file an exception called a “prior authorization” through your insurer, requesting that the drug be covered because it’s medically necessary. Your plan should approve or deny your request within a few days, and there is usually a mechanism for appeal.
GoodRx: I noticed a new tier on my formulary: non-preferred generic. What does that mean?
BBD: “Tiers” on insurance plan formularies are essentially a way to determine how much you’ll pay out of pocket for your medications. Most plans have about four levels, or tiers, of coverage, but in the last few years, many insurers have added a fifth tier by splitting the “generics” tier into two: One is “preferred” and the other is “nonpreferred.”
Companies do this to encourage you to choose less expensive medications. Your copay for a drug in the non-preferred generic tier, for example, may be $15, compared to a preferred generic in the lowest tier, where your copay could be $5 or less.
GoodRx: How does my deductible affect how my drugs are covered?
BBD: Your deductible is the set amount you need to spend each calendar year before your plan’s benefits kick in. In other words, you’ll pay full price for most services (including prescription medications) until you reach your deductible.
Some plans apply the “general medical” deductible to prescriptions as well, which means that the plan won’t make any payments for your medications until you’ve met your entire medical deductible. Other plans have a (generally) lower deductible that applies specifically to prescription coverage. Check with your insurer’s Summary of Benefits to find out how much you’ll pay out of pocket before your drugs are covered.
GoodRx: If my drug is no longer covered, can I appeal to my insurance plan to have it covered?
BBD: Yes, but it can be a lengthy process. You may have a few options, including the prior authorization route mentioned above. Depending on the medication, some plans may also require that you agree to “step therapy” first, which means trying other treatments before they approve the drug your doctor was going to prescribe. If the other treatments don’t work for you, you can work with your doctor to go through an appeal. You’ll need to fill out a form provided by your insurer or write a letter that include the name of the drug, why you need it covered, and any other supporting documents from your doctor. Your insurer can take up to 60 days to complete the appeal and get back to you.
If your insurance company denies your appeal, you can file for an independent review with your state’s insurance regulator, which will make the final decision. If your state doesn’t have an external review mechanism, the Department of Health and Human Services (HHS) or an independent review organization will oversee the process. This decision can also take up to 60 days. It’s free if handled by the HHS, but may cost you to $25 if it’s handled by your state or an independent review organization.
For more details on the appeals process, go to HealthCare.gov. For tips on how to write and submit an appeal, go to Patient Advocate Foundation (if you’re on Medicare, go to CMS.gov). To find your state regulator’s contact information, visit the National Association of Insurance Commissioners website.
GoodRx: In addition to the savings on GoodRx, what are some other ways to get help paying for my prescriptions?
BBD: Before you start a search for financial assistance, ask your doctor or pharmacist to review everything you’re taking; it could be that some of your medications are no longer needed.
If you’re facing high out-of-pocket costs, consider shopping around for lower prices. GoodRx price comparisons and Consumer Reports’ secret shoppers have found that prescription prices can vary widely from one pharmacy to the next, even in the same zip code.
If you don’t have health insurance or have a plan without drug coverage, look into applying for a patient-assistance program (PAP). PAPs have restrictions based on income, but if you qualify, you could get drugs at a deeply-discounted price, or even for free. For more cost-lowering tips, see Consumer Reports’ advice.
Consumer Reports Best Buy Drugs is a public education project dedicated to helping you talk to your doctor about prescription drugs and helping you find the most effective and safest drugs for the best price.