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Insurance covers fewer drugs than in 2010 and they're harder to get

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Insurance companies are covering fewer drugs than they used to and they're making patients jump through more hoops to get them. That's according to a new report called the Big Pinch, which shows how patients are pinched between drug companies and their health insurance. NPR pharmaceuticals correspondent Sydney Lupkin has more.

SYDNEY LUPKIN, BYLINE: Insurance companies' lists of covered drugs, called formularies, are shrinking. In 2010, the average Medicare formulary covered about three-quarters of all drugs approved by the Food and Drug Administration. Now it's a little more than half. That's according to new research by GoodRx, a website that helps patients find discounts on prescription drugs. GoodRx is an NPR funder. And Tori Marsh, the director of research at GoodRx, says commercial plans likely cover even fewer drugs than Medicare.

TORI MARSH: Far too often, people talk way too much about the cost of their prescription, and we're screaming about the high costs of prescriptions. But what we're not talking about is the poor coverage.

LUPKIN: What's more, according to the report, patients have to clear more hurdles to get the drugs that are covered by their insurance than they did 14 years ago. Half the drugs that are covered require things like prior authorization, in which insurers require doctors to take an additional step of justifying why they've written a prescription. This step can cause delays or deter them from filling the prescriptions altogether. Still, limiting formularies and restricting access has a purpose, says Jeromie Ballreich, a health economist at Johns Hopkins University. They give negotiating leverage to the part of your health insurance that deals with drug coverage called a pharmacy benefit manager.

JEROMIE BALLREICH: Their way to kind of combating the jump in prices or the jump in spending is to really kind of hardball negotiate with drug companies.

LUPKIN: So they'll say they don't like your offer, but if you lower the price, we can make your drug a preferred drug without prior authorization. The negotiated prices don't typically get passed directly to consumers as lower copays, but they can reduce pressure on insurance premiums. GoodRx says the formulary shrunk the most before 2020. Lately, they've stabilized somewhat. Here's Marsh again.

MARSH: It's hopeful to see that things are not getting worse, but I would love to kind of see this chart move in opposite direction with more drugs covered and fewer of those having restrictions.

LUPKIN: So far, however, she's never seen coverage expand.

Sydney Lupkin, NPR News.

(SOUNDBITE OF RED HOT CHILI PEPPERS SONG, "SCAR TISSUE") Transcript provided by NPR, Copyright NPR.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

Sydney Lupkin
Sydney Lupkin is the pharmaceuticals correspondent for NPR.