When you can't afford your medication: Rising drug costs imperil mental health treatment

Magdalin Fulce used to take three different prescription medications for anxiety and depression.

She doesn’t take any now, not because she doesn’t need it, but because she can’t afford it.

Fulce, 24, of Weir lost the Medicaid covering her prescriptions on her 19th birthday. She then signed up for AmBetter through the Affordable Care Act, which again provided coverage. But when she turned in her earnings as a self-employed hairdresser in 2019, she was unable to afford the premiums any longer. 

At times, she was paying as much as $100 or $200 for a month’s supply of Valium. So, she stopped taking it.

Fulce got her prescriptions through her primary care physician but believes she needs a psychiatrist’s evaluation. “But I don’t have $400 for a psych workup,” Fulce said.

She has struggled since, she said. “I’ll go three months doing well then maybe three months downhill.”

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Four months ago, she overdosed on Klonopin, landing in the mental word at St. Dominic’s Hospital in Jackson.

Many families stop buying these types of prescription drugs because of the high cost, said Tandi Karol Weaver Hawthorne, an educator and mental health advocate in Choctaw County.

When her late husband, David, was diagnosed with schizoaffective disorder in 1996, she said they paid up to $1,000 a month for his medication. If not for a combination of Medicare, a private drug plan and extended family support, they couldn’t have afforded his medication, she said.

Magellan Health Service, a national leader in behavioral health care management, found that mental health drugs now account for a fourth of all pharmacy spending by private insurance and about a third of pharmacy spending by public payers such as Medicaid. 

And that number is expected to increase 60% over the coming decade, the Centers for Medicaid and Medicare Services predicted.

In Mississippi, approximately 77,000 Medicaid beneficiaries had behavioral health diagnoses (a number that includes children but not infants) in state fiscal year 2019, according to Matt Westerfield, communication director for Medicaid. The three primary diagnoses are schizophrenia, bipolar disorder, and depression.

“The vast majority of that 77,000 – if not all of them – would be on some form of mental health medication,” Westerfield said.

Not having regular access to medication causes relapse

Availability of medication plays a major role in maintaining mental health, according to the study by the patient advocacy group Mental Health America.

“Sixty-nine percent of patients with medication access problems had adverse events compared to 40% for patients with no access problems,” according to Joyce West, director of the American Psychiatric Research Network.

Of patients with access problems, the studies found:

• 20% had emergency room visits.
• 11% were hospitalized.
• 23% had side effects significantly worsen — interfering with functioning and outweighing therapeutic benefits.
• 22% had an increase in suicidal ideation or behavior.
• 15% had an increase in violent ideation or behavior.
• 3% became homeless for more than 48 hours.

Most patients look first to their insurance companies to provide prescription coverage. Mississippi Insurance Department spokeswoman Beth Reiss said health insurance companies use lists to determine which drugs they will or won’t cover. 

Blue Cross/Blue Shield of Mississippi and United Healthcare did not respond to requests for information on how they construct these lists or the prior authorization process, which is how doctors attempt to convince the companies to cover the drugs not on their approved list.

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Westerfield said the cost of high-priced drugs shouldn’t affect those on Medicaid.

“For beneficiaries in regular fee-for-service Medicaid, there is a $3 copay for any drug regardless of what medication is prescribed, and children, pregnant women and long-term care residents are exempt from that copay,” he said. “In Medicaid’s managed care program, two of the plans don’t charge beneficiaries a copay for medications, and the third plan charges a $1 copay.”

There is a limit, however, of how many prescriptions Medicaid patients can receive — six. Those under 21 are eligible for more if medication proves necessary.

Pharmacists are ‘a crucial part of the treatment team’

Pharmacists also offer solutions through generic medications as well as transportation and delivery options, said Bob Lomenick, whose pharmacies in Oxford, Holly Springs, and Potts Camp treat more than 3,000 people. “A lot of people are on fixed incomes.”

He said that insurance companies are starting to realize that restricting access to needed medications can be detrimental in the long run. “Payers are finding out that patients that don’t take their medications correctly costs the system a lot of money,” Lomenick said.

New drugs are expensive, Lomenick said, noting that Latuda, a mood stabilizer and anti-psychotic, costs him $41 a dose, while the popular ADHD drug Vyvance costs him $10 a dose. “Those ADD drugs are being used a ton these days —s ome justified, some not.”

Terence H. Brown, a pharmacist at GAC Community Pharmacy in Canton, said many manufacturers work with patient assistance programs, such as RxAssist, RxHope and GoodRx.

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Teresa Parker, compliance director for Region 7 Community Counseling in West Point, says that connecting clients with patient assistance programs is a part of their plans to aid patients in getting their psychiatric medications. “It used to take only five days to be approved,” she said. “Now it takes three months.”

Delays and costs leads some patients to choose pills for physical ailments over mental health medication, she said. “If you rely on a fixed income, any new medicine, even a $60 medicine addition, that money has to come from somewhere.”

Fulce said that something more needs to be done so that mental health patients like her don’t fall between the cracks. “For someone who’s never had a severe mental health issue, they don’t have any understanding of what this is like. It’s not making it day to day— it’s more like minute by minute.”

This story was produced by the Mississippi Center for Investigative Reporting, a nonprofit news organization. Email Julie Whitehead at julie.whitehead.mcir@gmail.com.

Need assistance with medication?

Talk with your doctor

If you don’t have insurance, the first thing you should is speak with your doctor if you are having trouble affording your medication. They may be able to provide you with free samples for a period of time. It may also be possible to switch to a less expensive brand-name medication or the generic form of your medication.

Prescription assistance programs

Many states and counties offer prescription assistance programs. Contact your NAMI State Organization and NAMI Affiliate for information about programs in your area.

www.needhelppayingbills.com is a website that also lists state and local assistance programs.

Your state’s Medicaid office may have information about prescription assistance and discount programs.

If you participate in Medicare Part D and need financial assistance you may be qualified for the federal benefit program called Extra Help. The Medicare Rights Center — 1-800-333-4114 — can let you know if you qualify.

Nonprofit prescription assistance programs

NeedyMeds helps people of all ages, with and without insurance, locate patient assistance programs, free/low cost clinics, state programs and offers a free NeedyMeds Drug Discount Card. For more information, call its helpline at 800-503-6897.

Partnership for Prescription Assistance helps qualifying people without prescription drug coverage get the medication they need for free or nearly free. They offer access to public and private programs, including pharmaceutical company programs.

RxAssist helps individuals find information about free and low-cost medication programs and other ways to manage your medication cost through their online Patient Assistance Program Center. They also provide a prescription discount card that patients may be able to use even if they have health insurance coverage.

RxHope provides program descriptions and downloadable applications for prescription assistance programs for specific medications.

PatientAssistance.com is a nonprofit site that offers money-saving offers such as printable coupons and a searchable database of available patient assistance programs.

GoodRx allows you to compare drug prices from pharmacies in your area, including big pharmacy chains, local pharmacies and mail order companies.

Pharmaceutical companies

If you take the brand name version of a medication, the pharmaceutical company that makes that drug may offer payment assistance.