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Insurers Are Covering Far Fewer Drugs Than They Once Were

MARY LOUISE KELLY, HOST:

Health insurance is critical for patients who need expensive prescription drugs, but new research indicates that insurers are covering fewer drugs than they did a decade ago. NPR pharmaceuticals correspondent Sydney Lupkin reports.

SYDNEY LUPKIN, BYLINE: Leslie Miller is a 42-year-old cancer survivor. In December, her health insurance company sent her a letter to tell her it would no longer cover a drug she needs to cope with the effects of her treatment.

LESLIE MILLER: My heart started racing immediately because I've had this happen before, and it's scary.

LUPKIN: Miller was diagnosed with cancer when she was a teenager. She's cancer-free today but has lingering nerve damage. She needs a drug called Linzess to help her use the bathroom. That's the one her insurance dropped from coverage to push her toward a rival drug. Miller's doctor failed to convince the insurance company to let her stay on it. She doesn't want to switch because she's been doing so well on Linzess, and it only costs her about 30 bucks a month.

MILLER: So here I am in January needing this medication, and I had to pay $330 after the manufacturer coupon.

LUPKIN: She's not alone. Insurance companies lists of covered drugs called formularies are shrinking. CVS Caremark and Express Scripts, which handle drug coverage for many insurance plans, cut hundreds of drugs from their formularies. Many Medicare plans have, too. A decade ago, these plans covered almost three-quarters of available drugs. Now it's a little over half. That's according to an analysis by GoodRx, a website that helps patients get discounts on drugs. Thomas Goetz is chief of research at GoodRx, and he says this change can leave patients stranded at the pharmacy counter.

THOMAS GOETZ: So that can be a real shock to the system for people, and then the question is, well, OK. What do I do? My insurance won't pay for this.

LUPKIN: Sometimes, insurers have a good reason for dropping a drug. Harvard Professor Ameet Sarpatwari says there might be a better deal on a brand name drug or there's a generic available.

AMEET SARPATWARI: A lot of this could be an example of the way the market is supposed to work. You leverage that negotiating ability you have because of the existence of competitors, and you cover those that offer a good price for the product.

LUPKIN: The problem arises when the part of your insurance that deals with drugs called a pharmacy benefit manager cuts drugs that don't have good alternatives. J.C. Scott leads the trade group for pharmacy benefit managers. He says doctors and insurers don't always agree.

J C SCOTT: I think we're all collectively trying to grapple with higher drug costs from drug manufacturers, and we all have a part to play in trying to address those costs.

LUPKIN: Barbara McAnaney is an oncologist and past president of the American Medical Association. She thinks insurers should let doctors be doctors. Recently, she couldn't prescribe a cheaper drug because her patient's insurance would only cover the expensive one.

BARBARA MCANANEY: So the formularies seem to be determined by what is most profitable for the insurance company, not what is best for patients.

LUPKIN: She says dropping prescription drugs from insurance plans can be bad for patients, even if she finds a workaround.

MCANANEY: Well, emotionally, it's agony for the patient because they get increasingly scared, as anyone would. But medically, it's very bad to have an interruption in treatment.

LUPKIN: As for Leslie Miller, she's asked her doctor to appeal the insurer's decision.

MILLER: I'm going to fight, and that's what I do. (Laughter) That's what I do. I've done it my whole life with insurance companies.

LUPKIN: She just found out she won this round. After two and a half months of fighting, her insurer finally agreed to cover the drug.

Sydney Lupkin, NPR News. Transcript provided by NPR, Copyright NPR.