• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

Insurance Woes Add to Suffering; Over-the-Counter Allergy Meds Mean Some Sufferers Pay More

Posted on: Thursday, 2 June 2005, 00:00 CDT

Allergy season causes sniffling, sneezing, coughing and, for some, insurance headaches.

Insurance companies decide what medications they will cover. Brand-names usually cost the consumer more because the insurance company pays less of the cost.

And now Claritin, which used to be covered by insurance, is available without a prescription. That's helped some people get the medication without seeing a doctor and has saved them money, but it has cost others more because with their insurance co-pay, they paid less for the drug.

When a prescription isn't on a list or the insurance company increases how much a patient has to pay, people are faced with a choice: Pay more or change drugs.

That's the situation Renate Barshinger finds herself in this spring.

Barshinger, who is in her late 60s, said she has had problems with her lungs since 1996. She has multiple health issues, including allergies to trees and grass, chronic obstructive pulmonary disease, asthma, and stents propping open clogged arteries going to her heart.

This time of year, she spends most of her time in the air- conditioned basement of her old house in Seven Valleys, where she either crochets or watches television. Four times a day, she sucks in medicine and air through a nebulizer.

For two years, Barshinger didn't make any emergency visits to a hospital, as she had in years past. She believes that was because she was taking Zyrtec, an antihistamine.

Her primary insurance is Medicare, which doesn't have a prescription plan at this time. The current Medicare prescription- discount cards wouldn't save her any money, she said. AmeriHealth, a subsidiary of Independence Blue Cross, is her secondary insurance.

About two or three months ago, AmeriHealth increased the amount she was required to pay for Zyrtec from $25 to $50 for a month's worth, Barshinger said.

She couldn't afford it. She already was paying $700 a month for insurance. For one year, she spends about $3,400 on medications.

When she was working, Barshinger used to collect dolls, but she doesn't have the extra money anymore. She said it's difficult for her to pay the out-of-pocket cost for Zyrtec. Barshinger has tried Claritin-D, which is now over-the-counter, and Allegra, another prescription.

"Nothing worked except that one," she said of Zyrtec.

She doesn't understand why some medications are covered and others in the same drug class are not.

So she went two weeks without Zyrtec. She had coughing spells. She used her nebulizer every two hours.

On April 6, Barshinger was at the hospital again, receiving steroids and antibiotics. She spent eight days there.

"What gives the insurance company the right to say what medication you should take when your doctor knows what works?" she asked. "I don't think the insurance company has the right to do what it's doing."

Over-the-counter vs. prescription

Claritin and its generic version, loradatine, are available without prescriptions something that benefits some, but not others.

In 2002, the Food and Drug Administration approved Claritin as an over-the-counter product. At the time, it was seen as a milestone because the antihistamine, unlike older antihistamines such as Benadryl, didn't make people as drowsy.

Before Claritin became available in drugstores, it was the most- prescribed antihistamine, said Dr. Timothy Craig, a professor of medicine and pediatrics at Penn State Hershey Medical Center and Penn State College of Medicine.

Claritin's over-the-counter status has led to insurance companies' balking at covering other allergy medicines, Craig said. The companies want patients to try Claritin first, he said.

"It is a barrier, rather than a black-and-white-complete negotiation system," Craig said.

When he believes a patient would do better on another drug, he writes a letter to the insurance company. That's successful in about one-third of the cases, Craig said.

"Some people do end up spending the $75 or $80 a month for another prescription," he said.

Ann Perkins, a nurse manager with Allergy & Asthma Consultants in Spring Garden Township, said each insurance company is different and each plan offered by companies is different.

If a company doesn't cover a medication a doctor had planned to prescribe, the office submits the paperwork asking the company to cover it, Perkins said.

"The only reason (insurance companies) ever give us is this is what our doctors want to cover," Perkins said.

Some patients don't want to take certain medications, even if they are covered by insurance, because of side effects such as sleepiness or because they aren't getting relief from their symptoms, she said.

Sharon Hess, a medical assistant, with the Family Center for Allergy and Asthma in York Township, said her office doesn't usually have problems with getting allergy medicines covered once they write letters to the insurance companies.

"Sometimes, you do have to go through some hoops," she said. "I haven't had a flat-out, No, you can't have it,'" she said.

Insurers' decisions

When insurers make decisions about what drugs they will cover, they first consider whether a drug is the best available to treat a particular condition, said Mohit Ghose, spokesman for America's Health Insurance Plans. The national association represents 1,300 members that provide insurance to more than 200 million Americans.

Formularies lists created by insurance companies of drugs they will cover provide access to many different drugs in a cost- effective way, he said.

If every drug in a class was covered, it would be difficult for a health-insurance plan to negotiate better discounts, which would raise the rates passed on to employers and consumers, Ghose said.

"It's important, in the end, to look at this as an overall picture," he said.

If a drug isn't covered, a patient should work with the doctor and insurance company, then go to the human resources department of his or her employer because the employer picks the health plan, Ghose said.

At WellSpan Health's South Central Preferred, a preferred provider organization and third-party administrator that manages health care for self-insured companies in York, Adams and Franklin counties, the formulary is created by a separate company.

That company, Express Scripts, uses a process that involves three groups whose members look at a medicine's effectiveness. One of the three groups is composed of local doctors, said Barry Sparks, WellSpan Health spokesman.

HealthAmerica's solution to prescription costs that have doubled every five years is to use a formulary, Robert Dawson, president and chief executive officer of HealthAmerica and HealthAssurance wrote in an e-mail.

The company covers Allegra and Allegra-D as well as the over-the- counter generic forms of Claritin and Claritin-D, Dawson said.

Highmark Blue Shield generally covers one medication in each class, said Leilyn Perri, spokesman for Highmark.

Since some allergy medications are available over-the-counter, there has been a small decrease in the claims paid for prescriptions on the pharmacy side at Highmark, he said.

"Physicians often bend to the patient's demand for a covered Rx in many cases and switch to another covered brand," Perri wrote in an e-mail.

Craig said some doctors feel pressured by patients. Often, patients arrive for an appointment with some idea of what medication they want.

Not all allergy medications work the same way for everyone, Craig said. Zyrtec seems to control hives better. Allegra doesn't interact with other medications in the body, while Claritin may, he said.

Barshinger believes Zyrtec is the only one that makes her feel better. The other day, she spent $50 to buy a month's supply.

Her family doctor declined to comment on her situation.

James Rhodes, a spokesman for her insurance company, AmeriHealth, which is a subsidiary of Independence Blue Cross, could not comment on Barshinger's case but spoke generally about why Zyrtec was not covered.

"In the case of Zyrtec, the FDA has provided an equivalent product, in this case, Claritin, which is available without a prescription," Rhodes said.

Some other area insurance companies did not cover Zyrtec or offered restricted coverage of it, so patients would pay more for it than other allergy medications.

Barshinger said she just doesn't think it's fair.

"When you really need to be on something that helps you, my God, you pay through the nose," she said.

Reach Jennifer Nejman at 771-2026 or jnejman@ydr.com.

PICS: KRISTIN MURPHY Daily Record/Sunday News

Renate Barshinger inhales medicine through a nebulizer in her Seven Valleys home recently. Barshinger, who has asthma and allergies among other ailments, uses the nebulizer a few times a day. Each dose helps to ease her breathing problems for a few hours. She wishes her insurance company covered more of the cost of one of her allergy medications. Below: Barshinger said she spends $3,400 on medications for herself each year. Because of the allergies and asthma, she spends most of her time in her air-conditioned basement, where she crochets and watches television.

Source: York Daily Record

More News in this Category