Prices for common estrogen medications, widely used to treat symptoms of menopause, have doubled since 2014, increasing at a rate of about 15% each year.
More than 55 million women in the US are over the age of 51, the average age of menopause, and over half experience symptoms for which vaginal estrogen medications are prescribed. These hormone replacement therapies (HRT) are regularly called upon to counteract low estrogen levels after menopause and treat symptoms like extreme vaginal dryness, soreness, painful sex, and painful urination.
An analysis of GoodRx data on cash prices of estrogen drugs illustrates the substantial increase in recent years of out-of-pocket cost burden on women who need estrogen replacement therapy.
Estring, Estrace, and Vagifem, all brand-name medications used to treat menopausal changes in and around the vagina, have about doubled in cash price over the last four years. All three medications list estradiol, an estrogen drug that has existed for more than half a century now, as their main active ingredient.
The analysis is based on a representative sample of US prescription fills (not fills using GoodRx) and comes from several sources including pharmacies and insurers, providing a representative sample of nationwide US prescription drug volume. The following cash price data represent the full list prices at the pharmacy—the so-called “usual and customary” price. (It does not include insurance co-pays or co-insurance.)
Insurance Coverage Doesn’t Mean Good Coverage
Most patients with insurance through Medicare and the national health exchange are “covered” for these estrogen drugs. According to the MMIT formulary database, a large majority (68%) of Medicare patients are covered for Estring, and 71% of patients are covered for Estring through insurers on the health exchange. Similarly, 89% of Medicare patients and 87% of health exchange patients are covered for Estrace.
But insurance coverage doesn’t necessarily mean these medications are affordable. Although insurance plans claim to cover these estradiol products, they often place these medications in higher tier formularies, requiring patients to pay high out-of-pocket costs anyway.
Take Estring coverage for example. UnitedHealth Group, Inc., the insurer that currently serves the most Medicare lives, covers Estring for about 90% of their Medicare patients, according the MMIT data. However, they list Estring as a Tier 4 non-preferred drug in practically all of their Medicare insurance plans. It’s a similar story for Estrace—75% of UnitedHealth’s Medicare patients receive coverage for Estrace, but again, it’s listed as a Tier 4 drug in almost all plans.
Are Generics the Solution?
Many women in need of estrogen replacement therapy are exposed to skyrocketing drug prices because they either have weak insurance coverage or no coverage at all. Uninsured patients who paid less than $300 for a month’s supply of Estring in 2014, for example, now have to shell out $520 per month for the same medication.
As we see with Vagifem, generics can often provide hope for price containment. Vagifem is an estradiol tablet that is inserted into the vagina to replace estrogen levels in the vaginal wall and reverse thinning and dryness. Its cash price increased steadily to just over $200 for a month’s supply in 2016 when the generic, Yuvafem, received FDA approval.
A second generic entered the market in 2017, and now Yuvafem and that second generic cost about $160 and $130 for a month’s supply, respectively. Still, these prices are about the same as what the brand drug cost in 2015, when there was no generic competition.
With so many factors at play in drug pricing—from manufacturing costs to price negotiations between insurers and pharmacies, it’s difficult to say where prices will settle. In the case of Estrace, price growth has slowed since 2016, but the medication is still cost-prohibitive for many at about $370 for a standard tube.
At the end of last year (2017), the FDA approved a slightly less expensive generic for Estrace that runs at about $300 per tube. A generic for Estring, a medicated estrogen ring and the most expensive drug in this analysis by far, is not yet available.
Estring, Estrace, and Vagifem all offer manufacturer coupons to save eligible patients with poor or no insurance coverage anywhere from $40 to $100 per fill. Still, at hundreds of dollars per month for these hormone therapies, it’s no wonder that many women suffering from vaginal pain and discomfort from low estrogen levels just choose to go without and wait for cheaper solutions in the future.
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