Over the Counter, Yes, but Out of the Insurance Plan

The New York Times

July 4, 2004 Sunday
Late Edition – Final

SECTION: Section 3; Column 1; SundayBusiness; SUNDAY MONEY: SPENDING; Pg. 5

Over the Counter, Yes, but Out of the Insurance Plan


A YEAR ago, Carrie Howland's 4-year-old son, Bobby, who has Down syndrome and Hirschsprung's disease, which affects his colon, was taking one prescription heartburn pill a day. But when the medication, Prilosec, became available over the counter in June 2003, Bobby's insurer stopped paying for it.

The Howlands, of Shrewsbury, Mass., ended up paying about $30 a month out of pocket for the medication, on top of nearly $1,000 a month for his other health care needs, including insurance premiums, other medical supplies and frequent trips to the hospital. When the monthly premium on his insurance rose by $161 not long ago, Ms. Howland scoured her budget for possible savings.

''We have a comfortable income,'' she said. ''We're not skipping meals or are unable to heat the house. But every penny counts.''

She came up with an answer that might sound counterintuitive at first: she turned to a similar heartburn drug that required a prescription. But it was covered by insurance, meaning that her net expense was less.

While high prescription costs hog the spotlight, more and more consumers are being hit with another expense: over-the-counter drugs that aren't covered by insurance. Allergy drugs like Zyrtec and Claritin, as well as heartburn medications like Prilosec, can now be bought without a prescription, and drug makers are pushing to sell cholesterol drugs directly to consumers, too.

''It's good news and bad news,'' said Robert I. Field, director of the health policy program at the University of the Sciences in Philadelphia. ''The bad news is, you're not going to have insurers who'll want to cover O.T.C. drugs.''

Consumers may like the convenience of bypassing doctors and pharmacists when they need certain drugs, but it can be costly. For the year ended May 14, sales of over-the-counter health products were $25.6 billion, according to A.C. Nielsen, the marketing information company, up from $24.4 billion in the period ending in 2002.

Uninsured consumers and those with high co-payments have benefited most, health care experts say, because drugs are usually less expensive when they hit drugstore shelves, and prices tend to fall further as competitors appear. But for patients accustomed to having insurers picking up a big part of the bill, it is another story.

Much of the shift, Mr. Field said, stems from insurers seeking to reduce their expenses. It started, he added, in 2001, when WellPoint Health Networks of Thousand Oaks, Calif., petitioned the Food and Drug Administration to have allergy drugs like Claritin and Zyrtec sold directly to consumers. ''It was the first time an insurer wanted a drug to go O.T.C.,'' he said. ''It was the shot heard around the world.''

Drug companies also have a stake in offering medicine directly to consumers, said Eric J. Mack, assistant professor of pharmaceutics at the Massachusetts College of Pharmacy and Health Sciences in Boston. If a drug is losing patent protection, he said, it makes sense for the drug company to sell it over the counter and start a huge marketing campaign, in the hope that consumers will continue to buy a particular drug even if similar drugs soon enter the market. And with no prescription needed, he said, more buyers may appear.

Charles Ganley, director of the F.D.A.'s over-the-counter drug division, says that the only factors the agency considers in deciding whether to allow a drug to be sold over the counter are ''safety and effectiveness.''

''A lot of this is based on changes in society,'' he said. ''There is more emphasis, for whatever reason, on self-care.''

Consumers, of course, want to pay less for over-the-counter medications. In September, the Internal Revenue Service announced that individuals could use pretax dollars, through flexible savings accounts, to pay for such drugs. But vitamins and nutritional supplements are not eligible, and the cost of over-the-counter drugs cannot be deducted on a tax return.

Dr. Kathleen W. Wilson, an internal medicine specialist at the Ochsner Clinic in New Orleans, said her patients had various ways of coping. ''They do not buy lifestyle medicine such as Claritin unless they can afford it or their symptoms really bother them,'' she said. ''They adapt to the high price of reflux drugs by using them intermittently on the worst days and using the lower-priced drugs on the other days.''

And as many insurance plans raise the co-payments for prescription drugs, some consumers find that switching to over-the-counter medications — even if they are not covered by insurance — can save money, especially if they shop around.

Shev Rush, a publicist from Palm Springs, Calif., was taking prescription drugs for his allergies and acid reflux disease. Two months ago, when he switched insurance plans, his co-payment for Flonase, an allergy drug, rose to $65 from $15 for a month's supply. His co-payment for Protonix for acid reflux went to $90 from $30.

After some comparison shopping, Mr. Rush found Prilosec, an alternative his doctor had recommended for acid reflux, for less than $20 for a month's supply, and NasalCrom, an over-the-counter allergy drug, for about $10 for a month's supply.

''It's easier to buy O.T.C. than go through the hassle of using my insurance if the prices and efficacies are similar,'' he said.

Consumers may be uncomfortable bargain-hunting for a drug, but experts say they should do so. Linda Golodner, president of the National Consumers League, a nonprofit group in Washington, said that consumers should use coupons and consider buying in bulk, but also monitor expiration dates.

Consumers need to use the system to their advantage, as Ms. Howland did. A drug that is sold over the counter may still have a prescription counterpart that is covered by insurance, and the insurer can be consulted to compare out-of-pocket costs for prescription and over-the-counter drugs.

Some insurers may require patients to try over-the-counter drugs first. Kathleen Sheerin, an Atlanta allergist and the public education chairman of the American Academy of Allergy, Asthma and Immunology, says that many insurance companies require her to put in writing that a patient has tried over-the-counter medicines, without success, before going to a prescription.

Currently, most insurance companies do not cover over-the-counter drugs. But Fred Eckel, editor in chief of Pharmacy Times, said efforts to keep drug expenses down could push insurers to cover them someday. He pointed to a recent decision by the North Carolina Medicaid system to cover drugs like Claritin and Prilosec. If necessary, he said, consumers should review their choice of insurers when it is time to renew coverage.

MS. GOLODNER said consumers should also be wary of overusing over-the-counter medicines. ''People might think you can't overdose with these drugs and take two pills instead of one,'' she said, leading to higher costs and possibly health problems.

Consumers may also consider money-saving generic versions of over-the-counter drugs. Generics are similar to brand-name medicines, but certain ingredients, like binders, differ, said Devon Herrick, health economist for the National Center for Policy Analysis. It is important to talk to your pharmacist or doctor about possible generics, he added; if one drug disagrees with you or is ineffective, try another. Negative reactions are rare, but if they occur, he said, stick with the brand name.

Over-the-counter drugs, of course, are not sold only at the drugstore. They are increasingly showing up at supermarkets and wholesale clubs, and on the Internet. Mr. Herrick said consumers should be wary of unknown sites. But online branches of retail stores and sites like Drugstore.com have proved reliable, he said.

With the increase in shopping choices and ease of use, the chances for harmful drug interactions will rise, said Mr. Mack of the Massachusetts College of Pharmacy. Keep track of the drugs you take and how they interact, he advised, and keep your doctor abreast of your self-medicating.

If your insurer covers the bulk of your prescription bill and your copayments are low, you will probably have to pay more money when a medication starts to be sold over the counter. But there are ways to ease the burden:

FIND OUT — if a similar drug — one that works as well, with few or no side effects — is available by prescription, and covered by your insurer.

CHECK — with your local pharmacist or doctor about less-expensive generic alternatives among over-the-counter drugs. Because of possible differences between generics and name brands, compare effectiveness and any adverse reactions.

ASK — your insurer if it will pay for any over-the-counter drugs, and review your insurance choices during the open-enrollment season to see if any plans offer the coverage. Many health care experts expect that some insurers will pick up a portion of the over-thecounter bill soon.

SHOP AROUND — for bargains. But if you buy in bulk, pay strict attention to expiration dates, and do not forget about shipping costs when buying online.

Copyright 2004 The New York Times Company
The New York Times

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