Division of Urology, Department of Surgery, Cedars-Sinai Medical Center.
Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA.
Urogynecology (Phila). 2023 Feb 1;29(2):287-294. doi: 10.1097/SPV.0000000000001307.
Lower urinary tract symptoms (LUTSs) affect more than half of all adults, yet clinical care remains poor. Anecdotally, patients and health care providers express frustration over obstacles from insurance providers to obtaining LUTS treatment; however, little information concerning actual patient-incurred costs for these medications is available.
This study aimed to analyze coverage by 5 major insurance companies and patient costs for LUTS pharmacotherapy.
For each of 5 major nationwide insurance providers (Aetna, Blue Cross/Blue Shield, Cigna, Humana, United HealthCare), formulary coverage of medications for overactive bladder, interstitial cystitis/bladder pain syndrome, and genitourinary syndrome of menopause were reviewed for low- and high-cost plans. When not covered, the best preinsurance cash price of medications was determined from GoodRx.
This qualitative analysis demonstrates that no guideline-directed therapy was universally covered by all insurance providers at low cost, regardless of the availability of generic alternatives. Medication prices ranged from $3 to $900 per month across plans. Inconsistencies in coverage and medication prices were common across insurance providers, between similar medications used for treatment of a given condition, and between a provider's low- and high-cost plans.
Even medications that are U.S. Food and Drug Administration-approved and indicated by guidelines can have patient costs that are prohibitive. Because lack of care for LUTSs profoundly affects quality of life, the ability to live independently, and overall morbidity, improved price transparency is required to understand the health implications of limited coverage on LUTS care.
下尿路症状（LUTS）影响了超过一半的成年人，但临床治疗仍然很差。据传闻，患者和医疗保健提供者对保险提供商在获得 LUTS 治疗方面设置的障碍感到沮丧；然而，关于这些药物实际给患者带来的成本的信息很少。
本研究旨在分析 5 家主要保险公司的承保范围和 LUTS 药物治疗的患者成本。
对于 5 家主要的全国性保险公司（Aetna、Blue Cross/Blue Shield、Cigna、Humana、United HealthCare）中的每一家，都审查了用于治疗膀胱过度活动症、间质性膀胱炎/膀胱疼痛综合征和泌尿生殖系统绝经综合征的药物的低费用和高费用计划的配方覆盖情况。当未涵盖时，从 GoodRx 确定药物的最佳保险前现金价格。
这项定性分析表明，无论是否有通用替代品，没有一种指南指导的治疗方法能被所有保险公司以低价普遍覆盖。药物价格在不同计划中每月从 3 美元到 900 美元不等。在保险提供商之间、用于治疗特定疾病的类似药物之间以及提供商的低费用和高费用计划之间，普遍存在覆盖范围和药物价格的不一致。
即使是美国食品和药物管理局批准并由指南指示的药物，其患者成本也可能是令人望而却步的。由于缺乏对 LUTS 的治疗会严重影响生活质量、独立生活能力和整体发病率，因此需要提高价格透明度，以了解有限的覆盖范围对 LUTS 护理的健康影响。
