Dr. Katherine Shapiro on coverage and pricing for overactive bladder medications

Opinion
Video

“When you're talking about Medicare patients who are on multiple medications, and this is not the only thing that they're taking, to pay over $100 for 1 medication is sometimes not possible,” says Katherine Shapiro, MD.

In this video, Katherine Shapiro, MD, shares notable findings from the Urology paper “Analyzing Access and Costs of Oral Medications for Overactive Bladder (OAB): Uncovering Disparities?” Shapiro was a fellow in female pelvic medicine and reconstructive surgery at New York University in New York, New York at the time of the study.

Transcription:

What were some of the notable findings? Were any of them surprising to you and your coauthors?

We found that for Medicare beneficiaries, as we suspected, the out-of-pocket costs for these medications vary widely depending on the plan, the medication, and the coverage phase that the patient is in. And I just want to briefly talk about the coverage phases on a very basic level for clinicians to understand because it's a very confusing process. There are 4 coverage phases. The first one is the uninsured price before a deductible is met. The deductible is usually set at about $480, and the patient's really paying just an uninsured price for this. Once they meet that, they then pay a copayment or coinsurance, which is set by each plan. So it varies. And then once they reach about $4000, they fall into the coverage gap, and they pay 25% coinsurance up until about $10,000, when they reach the catastrophic phase. That's a 5% coinsurance price. In the catastrophic phase, the prices get really cheap, but the patient has to reach a very high cost before they fall into that phase. We found that most plans provide coverage for generic anticholinergics and mirabegron [Myrbetriq]. But not all coverage is created equal. So although coverage may sound good, it doesn't actually mean that the patient can still get it. Surprisingly, we found that mirabegron had a median copayment of only $47, which is actually pretty cheap, and 100% of plans covered mirabegron. There also were very minimal step therapy and prior authorization requirements; only 0.6% of plans required step therapy, and 0.1% of plans required prior authorization. Despite this, we found that mirabegron still may be cost prohibitive prior to deductibles because the average uninsured price is $517. Also, when a patient falls into that coverage gap, the price is about $130. And when you're talking about Medicare patients who are on multiple medications, and this is not the only thing that they're taking, to pay over $100 for 1 medication is sometimes not possible. We also found additionally, that more selective generic anticholinergics, like solafenacin, tolterodine, or darifenacin, have pretty significant step therapy requirements prior to being covered. That means that patients must try cheaper therapies before they can get those approved. Often, this cheaper medication is oxybutynin. That's a nonselective anticholinergic, which a lot of providers try to avoid, because that one medication has really been associated in the literature with cognitive impairment with long-term use. So providers really try to avoid this medication. That's why there's been all these new selective medications and beta 3 agonists - to try and really avoid that one medication. It has been around the longest, it does work very well, but it does have some negative side effects. So although medications with fewer side effects such as beta 3 agonists and selective anticholinergics appear to really be covered pretty well, the prices for these drugs are high, and there are many hurdles that patients have to jump through in order to get these drugs. Interestingly, for patients who can afford the initial cost of mirabegron, that $500, the total yearly cost for mirabegron is actually lower than most brand-name anticholinergics and some of the more selective generic anticholinergics. This is because the copayment is so low, and that patients reach that deductible so fast, with such a high uninsured cost of it being $500. This is encouraging overall for patients to continue this medication because costs can be lower once that hurdle has been reached. Often, I will say to patients, "If you can get over that initial sticker shock of that first or second month, the price really does substantially drop." When it came to looking outside of insurance, like at GoodRx, it's not as simple with GoodRx as to whether that may help or not. It's not very beneficial to use GoodRx when it comes to brand-name anticholinergics or beta 3 agonists. And when it comes to the generic anticholinergics, it really depends on what coverage phase the patient is in as to whether it will be cheaper or more expensive to use the coupon. Finally, although Mark Cuban's Cost Plus Drug Company offers very low prices, there are a limited number of drugs available on this site. When we did our data collection, there were only 3 medications available. But these medications were cheaper than any GoodRx coupon or any Medicare coverage phase. So it's really important for providers to familiarize themselves with this company, because the prices are so cheap, and also the medications are changing. It's not always the same medications that are going to be available on that site. They may add some; they may take some out, so it's constantly changing.

This transcript was edited for clarity.

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