Wow, That [Copay] is Depressing
Whether a medication actually makes a patient feel better or improves their blood glucose, their blood pressure, or their labs, that medication makes a difference. I am not going to debate whether mental health or physical health is more important because there is no debate to be made; they are simply both imperative. Proper mental and physical health are vital for our existence and many of us need medications to help promote at least one of these states. Any of these medications can be life-saving medications for chronic conditions; yet common chronic mental health prescriptions may cost an average of nearly 340% more than chronic cardiovascular prescriptions for Medicare patients.
Methods
We compared the copay amounts of our prescriptions (Rx) of interest among four Medicare Part D plans (Clear Spring Health Premier Rx (1), SilverScript Smart Rx (2), Elixir RxPlus (3), and Blue Rx Complete (4)) at four different pharmacies (CVS, Rite Aid, UPMC Community Pharmacies, and mail order) within the Pittsburgh area (15219 zip code). Our review included 8 cardiovascular Rx, 6 mental health Rx, and 4 “other” (GERD, asthma, and hypothyroid) Rx; each of our medications were compared at 30 oral tablets or capsules of approximately average dosages. These medications were chosen based on the top 50 drugs dispensed, excluding non-oral dosage forms and acute therapies.
Our cardiovascular health Rx included:
Atorvastatin
· Lisinopril
·Amlodipine
· Metoprolol succinate
· Losartan
· Simvastatin
· Furosemide
· Metformin (not truly cardiovascular in nature but fit best in this category)
Our mental health Rx included
Ø Sertraline
Ø Escitalopram
Ø Bupropion XL
Ø Trazodone
Ø Generic Adderall
Ø Fluoxetine
Our “other” Rx included
o Omeprazole
o Pantoprazole
o Montelukast
o Levothyroxine
The average price per month before and after Medicare patients reached their deductibles for each of these cardiovascular Rx was $10.81; this is the least expensive class of medications and one monthly medication from this category still adds up to about $130 per year. The average price of each of the “other” Rx was $13.65, a total of about $165 per prescription per year-a noticeable but not extreme difference between categories. The final and by far most expensive category, mental health Rx, cost a substantially higher fee of $47.35 per prescription per month on average. The yearly average of one mental health medication alone adds up to nearly $570.
That’s five hundred seventy dollars for a year’s worth of one medication, assuming that there are no urgent dose adjustments between fills, no other prescriptions, and generally no problems. That is also the average; therefore, some patients pay less than $570 per year but some patients pay MORE!
This difference in mental health and cardiovascular medications is roughly 340% on average. There is, on average, a higher acquisition cost for mental health medications; however, it is not over 300% or even 200%. Excluding generic Adderall, the average acquisition cost [at Blueberry Pharmacy] is only about 85% higher for mental health Rx than cardiovascular Rx. Including generic Adderall, the cost jumps to about 180%. Even factoring in the higher acquisition cost, Medicare patients are still paying disproportionately higher copays on mental health Rx than cardiovascular Rx (again, about 340% higher).
Why is the payment for mental health medications disproportionately higher than cardiovascular medications?
Q. Are they more popular?
A. All the selected medications are typically within the top 30 oral prescriptions in the United States. (5)
Q. More valuable?
A. To reiterate, these particular mental health medications have a higher acquisition cost on average than the selected cardiovascular medications; however, the acquisition cost and patient copay is not proportional for mental health medications compared to cardiovascular medications.
Q. Are Medicare plans trying to deter the use of these mental health medications with inflated prices due to geriatric precautions?
A. Some mental health medications should be avoided in older adults but generally the selected medications are appropriate for use in geriatric patients. SSRIs are to be used with caution in older adults due to the risk of low sodium; however, sertraline has generally well-tolerated side effects and is considered a preferred SSRI for older patients. (6) Escitalopram is not a preferred SSRI in older patients but is also safe for use; furthermore the only additional precautions compared to adult dosing are serum sodium monitoring and potentially initiating therapy with a lower dose (5mg vs 10mg). (7) Bupropion should be used with caution due to the risk of metabolite accumulation but it is considered a good alternative antidepressant due to its tolerable side effect profile. (8) Trazodone is also to be used with caution due to sedative properties but has few anticholinergic effects so it is not unfavorable. (9) Additional precautions should be taken with Adderall due to its stimulating effects but it can also be used in older adults at a lower starting dose than adults. (10) Fluoxetine’s less tolerable side effects and long half-life make it a less favorable SSRI in elderly adults; (11) however, older adults who have been stabilized on and tolerate fluoxetine may continue therapy without disruptions. Generally, mental health medications should be used with caution in elderly patients but these Rx are not contraindicated in patients who would have Medicare coverage.
Q. Is medication adherence worse for mental health medications?
A. Perhaps Medicare plans are trying to compensate for wasted medications due to poor adherence by charging more. Unfortunately, medication adherence for major depressive disorder (for which most of these mental health Rx are used) is 50% and on average medication adherence for mental health medications is about 50%. (12) However, medication adherence for cardiovascular meds is frequently as low as <40%. (13)
Q. Do cardiovascular meds improve quality of life further than mental health meds?
A. When prescribed and taken appropriately, any medication can improve patient outcomes and quality of life.
Quality of life, physical health, mental health, and even life-saving may be defined differently for each individual but care must be given equally to each of these fundamentals for every patient. Providing quality care is improving health equity among all patients, not targeting an already-marginalized patient population with predatory prices. Health equity is meeting patients where they are, not overcharging patients for medications that treat a specific stigmatized set of disease states. Mental health matters and patients deserve to pay equivalent prices for all medications, regardless of their indications.
*Plan and purchase values are all as of August 26, 2021 and are subject to change
References
5. DrugReport. The 50 Most Commonly Prescribed Drugs in America And Their Average Price. Accessed August 26, 2021. https://www.drugreport.com/50-commonly-prescribed-drugs-in-america/
6. Sertraline. Lexi-Drugs. Lexicomp Online. Lexicomp; 2021. Accessed August 25, 2021. http://www.crlonline.com.authenticate.library.duq.edu/lco/action/doc/retrieve/docid/patch_f/7662?cesid=aa8n7o6dksg&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dsertraline%26t%3Dname%26va%3Dsertraline#cpg
7. Escitalopram. Lexi-Drugs. Lexicomp Online. Lexicomp; 2021. Accessed August 25, 2021. http://www.crlonline.com.authenticate.library.duq.edu/lco/action/doc/retrieve/docid/patch_f/6846?cesid=1YKKklAWFDf&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Descitalopram%26t%3Dname%26va%3Descitalopram#doe
8. Bupropion. Lexi-Drugs. Lexicomp Online. Lexicomp; 2021. Accessed August 25, 2021. http://www.crlonline.com.authenticate.library.duq.edu/lco/action/doc/retrieve/docid/patch_f/6485?cesid=0tO9DDHYbxs&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dbupropion%26t%3Dname%26va%3Dbupropion#doe
9. Trazodone. Lexi-Drugs. Lexicomp Online. Lexicomp; 2021. Accessed August 25, 2021. http://www.crlonline.com.authenticate.library.duq.edu/lco/action/doc/retrieve/docid/patch_f/7804?cesid=3GkaU3AzBSC&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3DTrazodone%26t%3Dname%26va%3DTrazodone#doe
10. Adderall. Lexi-Drugs. Lexicomp Online. Lexicomp; 2021. Accessed August 25, 2021. http://www.crlonline.com.authenticate.library.duq.edu/lco/action/doc/retrieve/docid/patch_f/6721?cesid=2m3iIerduEA&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dadderall%26t%3Dname%26va%3Dadderall
11. Fluoxetine. Lexi-Drugs. Lexicomp Online. Lexicomp; 2021. Accessed August 25, 2021. http://www.crlonline.com.authenticate.library.duq.edu/lco/action/doc/retrieve/docid/patch_f/6931?cesid=6rTcVK8qWYk&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3DFluoxetine%26t%3Dname%26va%3DFluoxetine#doe
12. Semahegn A., Torpey K., Manu A. et al. Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis. Syst Rev 9, 17 (2020). https://doi.org/10.1186/s13643-020-1274-3
13. Baroletti S, Dell’Orfano H. Medication Adherence in Cardiovascular Disease. Circulation. 2010;121:1455–1458. https://doi.org/10.1161/CIRCULATIONAHA.109.904003
