WHY YOU NEED TO UNDERSTAND YOUR RX DRUG PLAN
Diabetes medications have changed dramatically over the past decade. Years before, there were far fewer options for treatment. Because there were few options for treatment, prescription drug coverage was more straightforward and cost was rarely an issue. In addition, the patient-doctor relationship was simpler and more paternalistic. Now, we face a world in which there have been tremendous advances in technology for treating diabetes. The patient-physician relationship has also evolved into a healthier collaboration. Since we have more options and patients are more involved in their care, doctors can tailor diabetes therapy to a person’s specific needs. However, this beneficial progress has created a new challenge. With more options comes more complex decisions, and more variations in possible treatment plans. Because insurances vary so much, the knowing the cost of different treatment plans is very difficult to determine up front. Since cost is being shifted more onto patients, this throws the decision-making process into chaos since we can decide upon a treatment plan only to have it blocked by the insurance company, making us have start over. This results in causing you frustration, delaying your treatment, and potentially requiring another doctor’s visit.
Diabetes therapy requires combinations of potentially expensive drugs
There are now 10 different medication classes commonly used to treat diabetes. “Medication class” can be defined as a set of medications that have similar chemical structures, the same mechanism of action, and are used to treat the same disease. These different classes of medicine allow us to attack diabetes in multiple ways. Most of the time, we use combinations of medication classes together to achieve additive (or synergistic) effects to treat diabetes. It is common nowadays to use 2-3 different medication classes at the same time. Within a diabetes medication class, there can be 1- 6 members. While medications within a class are very similar, there are still potentially important differences. There are 4 characteristics of drugs that are considered when making a treatment plan.
Drug Characteristics Doctors Consider When Making a Treatment Plan
Effectiveness
By effectiveness in diabetes medications, we focus on how well a medicine lowers the glucose levels, as evidenced by changes in A1C. Different drug classes have different A1C lowering potential. Some drugs within the same class may lower an A1C more than another member of the class.
Side Benefits
Different medication classes have additional benefits beyond just A1C lowering. One class may help heal liver damage related to diabetes, while another class may give extra protection to the kidneys. Even within the same class, some medications have additional proven benefits that other members in the class may not have (or at least have not been proven to have). These “side benefits” can be very extremely important, and is an important component to tailoring a diabetes therapy that is specific to YOUR needs.
Risks and adverse effects
All diabetes drugs have adverse side effects (such as diarrhea, for example) and have risks. Based off your medical history, you may be more susceptible to risks from one medication class, and less susceptible to risks from another medication class. There are sometimes very scary sounding risks for medications that have almost no chance of impacting you whatsoever—it all depends on your medical history. Tailoring therapy to minimize the specific risk to YOU is one of the most important roles an doctor considers.
It must also be mentioned that once again, there are sometimes risks specific to a certain medication that have not been shown in other medications in its class.
Cost
The cost of a medication is extremely tricky to pin down. The pricing starts with the manufacturer suggested price. Then, there is the price that the insurance company pays for the medication (this price is negotiated at least once a year, and is far lower than the suggested price). From there, the price that you will pay depends on your agreement with the insurance company, as your policy explains what portion of the cost you will pay. Certain drug classes inherently cost less than other drug classes. But even drugs within the SAME CLASS can have vastly different costs. Doctors are kept in the dark with regard to how much each a drug will cost you. While one patient may pay $5, the next patient may be charged $500.
Creating a Diabetes Treatment Plan
When you and your doctor come up with a medication combination, the combination has to take into account the 4 factors (effectiveness, side benefits, risks, and costs). Doctors are experts on the first 3 factors, but we need your help in determining the cost. We have to work within the medical system we have, and it is undeniable that cost plays a critical role in determining what therapies will strike the best balance of effectiveness, risks, and costs. Don’t rely on the doctor to “figure it out” for you. At best, this is going to delay access to your medications. At worst, you won’t have access to safest and most effective treatment for your condition, which places you at higher out-of-pocket cost and higher risk.
Key point: Our goal is to work the system to put the odds in your favor in minimizing your cost and risk, while maximizing effectiveness and side benefits. Doctors need your help to do this, we cannot do it alone
Doctors need your help to figure out what a drug will cost you
The cost of a medication is extremely tricky to pin down. The pricing starts with the drugmaker’s suggested price (this is called the list price). From there, a pharmacy benefit manager negotiates on behalf of your insurer to determine a lower price (often times 40% or more lower from the list price).It is this negotiated price that primarily determines what a drug is going to cost you. You may pay more or less depending on the pharmacy, due to separate negotiations that determine how much a pharmacy pays for that drug and how much they charge to dispense the drug. However, determining whether or not a drug is going to be affordable for you primarily depends on how much your insurer paid for the drug.
Your insurer will push you to use the drugs they get a better deal on
From there, the price that you will pay depends on your agreement with the insurance company. Your insurer puts rules in place to steer you toward the drugs that they paid the least for. Using a diabetes-related example, consider the GLP-1 agonist drug class. There are 5 drugs in this class (Byetta, Bydureon, Victoza, Trulicity, and Ozempic), and all have a similar list price. The insurer negotiates with the drugmaker of each of these medications to try to get the lowest price. Whichever drugmaker gives the best discount will, in turn, get the most favorable placement on the insurers formulary (see below). you, as the patient, will charged dramatically different amounts depending on how the drug is listed in the formulary– You may be charged just 2% of the drugs’s list price or 100% of the drug’s list price!
Doctors are not aware of what your insurers have negotiated with the drugmaker or what their contract with you says either. One patient may pay $25 for a drug whereas the next patient may be charged $800.
You need to understand your prescription drug insurance
Diabetes drugs are extremely expensive and the drugmakers are competing fiercely between each other to get on insurance company formularies. The insurance companies take advantage of this by frequently changing their formulary to get one drugmaker to reduce their price below the price of their competitiors. While theoretically this is good for people with diabetes, in practice it causes you a big problem– Insurances are rejecting prescriptions more and more due to complicated formulary rules and changes. Patients are expected to be far savvier with their healthcare than they ever were before. If you have diabetes, you either choose to learn about your formulary or else you will face hundreds of dollars of unnecessary costs and reduced access to medicine.