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Gender Detriments in Health Plan Benefits
Anna C. Naples, Pharm. D. Candidate, UNC-CH Class of 2003 David Work, JD,Executive Director of the North Carolina Board of Pharmacy, Adjunct Professor at UNC-CH School of Pharmacy Anna Naples 24 Warbler Lane Durham, NC 27712 Phone 919-593-1199 Fax 919-967-5757 Email-anaples@ncbop.org Abstract
The Pharmacy Board receives many calls about health plan payments and from women questioning the coverage of contraceptives, which led to the comparison of benefits for males and females. In 1999, the North Carolina General Assembly passed an act requiring that health insurance plans provide coverage for Food and Drug Administration (FDA) approved prescription contraceptive drugs, devices, and related medical examinations if they offer prescription drug coverage. The act was effective as of January 1, 2000 and although this act has been effective for almost 2 years, it appears that health plans have interpreted this act in such a way that still provides little benefit to some The percent benefit paid by six popular health plans in North Carolina on 10 prescription medications, five of which were commonly used by females and five of which were commonly used by males were compared. This study indicates there is significant variability between health plans and how much benefit they provide their patients. It also indicates that these benefits differ depending on gender. Three of the six plans examined had higher benefits for female patients and the other three plans analyzed showed greater benefits to male patients. If the medications, which were included by the plans but provided a 0% benefit to the patients, were included in the average benefit calculations, only one plan provides its female patients with a greater benefit than Introduction
The Pharmacy Board receives many calls about health plan payments for drugs even though the Board has no jurisdiction over this subject. Inquiries include topics such as the extent of benefits, the coverage of brand and generic drugs, different co-payment amounts and public health concerns over an adequate number of pharmacies participating in the State Employees Health Plan. Some women question the coverage of contraceptives, which led to the comparison of Background
Many people assume that their health plan provides them with fair and equal prescription drug benefits regardless of their gender. Unfortunately with some health plans their assumption is incorrect. Although co-pays for brand or generic medications are the same regardless of gender, the actual benefit paid by health plans may depend on more than the price of the medication alone. Until 1999, there was no law in North Carolina requiring health plans to cover oral contraceptives for female patients. However, in 1999, the North Carolina General Assembly passed an act which requires that many health insurance plans provide coverage for Food and Drug Administration (FDA) approved prescription contraceptive drugs, devices, and related medical examinations if they offer prescription drug coverage. The act was effective as of January 1, 2000 and although this act has been effective for almost 2 years, it appears that health plans have interpreted this act in such a way that still provides little benefit to their patients. Some health plans increased their co-pays after the act was passed from $10 to $25. If the product cost to the pharmacy is $29.86 and the pharmacy fee is $1.50, the overall expense is $31.36. The consumer pays $25 as the co-pay and the health plan pays the remaining $6.36 to the pharmacy. Therefore, while the health plans technically cover oral contraceptives, the patient is left with nearly all of the expense. This may comply with the letter of the law, but certainly not the intent. This is a slender benefit when the patient’s monthly premium is over $200 per month (State Employees single coverage is $244/month and is publicly available information). This minimal benefit is very significant because there are approximately 188,000 female patients compared to approximately 92,000 male patients on the state health plan. If some plans have increased the cost of oral contraceptives and decreased their benefit to female consumers, are the other health plans, likewise, giving lower benefits to females? Methods: Study Design
The answer was researched by comparing the percent benefit paid by six popular health plans in North Carolina on 10 prescription medications, five of which were commonly used by females, and five of which were commonly used by males. A list of possible drugs targeted to each gender was narrowed down to cover a wide range of FDA approved indications for each gender and specific drugs studied were chosen using their FDA labeling. The six health plans included in the study were selected based on their patient volume for prescription drugs. Those studied included Blue Advantage by Blue Cross and Blue Shield of North Carolina, Cigna Healthcare of North Carolina, Partners National Health Plan of North Carolina, United Healthcare of North Carolina, North Carolina Teachers’ and State Employees’ Major Medical Five medications were selected as being drugs commonly used by male patients to include in the evaluation. Androderm® (transdermal testotsterone), is indicated by the FDA for testosterone replacement therapy in men for conditions associated with a deficiency or absence of testosterone. The product has not been evaluated in women and therefore is not recommended for use in women. A 30- patch supply of the 5 mg strength was used in the study as a 30-day supply unless otherwise stated. Flomax® (tamsulosin) is indicated for the treatment of the signs and symptoms of benign prostatic hyperplasia (BPH) or enlarged prostate, but is not indicated for the treatment of hypertension, and thus is not indicated for use in women. Thirty dosage units of Flomax® were considered a 30 day supply for the study unless otherwise stated. Muse® (urethral alprostadil) is a urethral suppository with FDA indication for the treatment of erectile dysfunction. One box (6 suppositories) of the 125 mcg strength was considered a 30 day supply in this study unless noted otherwise. Propecia® (finasteride) is for the treatment of male pattern hair loss (androgenetic alopecia) in men only. Unless otherwise noted, a 30 days supply was considered to be 30 dosage units of 1 mg for this study. Viagra® (sildenafil) is FDA indicated for the treatment of erectile dysfunction and may only be used in men according to FDA indication. For this study, a 30-day supply was considered 5 dosage units of 50 mg unless otherwise Five drugs were also selected for the evaluation of benefits to women. Diflucan® (fluconazole) has FDA indication for the treatment of vaginal candidiasis (vaginal yeast infections due to Candida), Oropharyngeal and esophageal candidiasis and Cryptococcal meningitis. The recommend dose for vaginal candidiasis is 150 mg once and therefore, 4 of these were considered a 30- day supply unless otherwise noted for this study as women more frequently use this dose than men. Evista® (raloxifene) is indicated for the treatment and prevention of osteoporosis in postmenopausal women. There is no FDA indication for its use in men and the risk of suffering a bone fracture due to osteoporosis over the course of life is about 40% for women, and 13% for men. Thirty dosage units of Evista® were considered a 30-day supply for the purpose of this study unless otherwise noted. Nolvadex® (tamoxifen) is indicated for the treatment of metastatic breast cancer in women and men, to reduce the incidence of breast cancer and to treat other related diseases. A 30-day supply of thirty, 20 mg dosage units of the medication in a generic equivalent was used in this study unless otherwise specified. Ortho Tri-Cyclen® (ethinyl estradiol/norgestimate) is FDA indicated for the prevention of pregnancy in women who elect to use oral contraceptives as a method of contraception and for the treatment of moderate acne vulgaris in females, ≥ 15 years of age, who have no known contraindications to oral contraceptive therapy, desire contraception, have achieved menarche, and are unresponsive to topical anti-acne medications. One pack of 28 pills was considered a 30-day supply unless otherwise noted for this study. Premarin® (conjugated estrogens) is indicated for the treatment of vasomotor symptoms associated with menopause, vaginitis, kraurosis vulvae, female hypo-gonadism, primary ovarian failure, breast cancer palliation, palliation prosthetic carcinoma, postpartum breast engorgement, abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology. For this study, a 30-day supply was considered 30 dosage units of the 0.625mg strength unless otherwise stated. Please refer to Table 1. To calculate the benefit provided by each health plan on the ten medications, the payment made by the health plan was divided by the total charge for each prescription. The total charge was calculated using the amount accepted by the health plan as the cost of the medication plus the fee paid to the pharmacy by the health plan for each dispensing of a prescription. The payment made by the health plan was calculated by subtracting the co-pay paid by the patient from the total charge for each prescription. Not every product was covered by every health plan reviewed. Some plans, while not declining to cover the medication, provided no benefit to the patient. Many plans also decreased their benefit by limiting the amount of United Healthcare of North Carolina did not cover Propecia®. Due to this, the benefit would actually be 0%, however since the product was listed as not covered, it was not included in the average. They limited the number of Diflucan® dispensed to 1 tablet each time, therefore the benefit was calculated using the cost and co-pay for 1 tablet. Although the drug product was not listed as not covered United Healthcare patients are required to pay the total charge of their Diflucan® as their co-pay. Because the benefit was 0, it was not included in the average. If the 0% benefit was included in the average since the product was listed as covered, however, the benefit would be only 45.9% for female patients. State Employees did not cover Muse®, Propecia® or Viagra®, and therefore these were benefits of 0% and were not included in the average. Premarin® had a percent benefit of 0 however it was not listed as not covered by the health plan. The benefit of zero was not included in the average. However, including the benefit of 0% brings the average down to 40.7% for female patients The Partners plan did not cover Muse®, Propecia® or Viagra® and these were not included in the average percent benefit calculations. The plan limited Diflucan® to 2 tablets per dispensing and therefore the calculations were made on only 2 tablets. Partners did not cover the generic equivalent for Nolvadex®, tamoxifen, however they did cover the brand name product and the calculations were based on the cost and co-pay for the brand name medication. Cigna Healthcare also did not cover Muse®, Propecia® or Viagra® and none of these were included in the average benefit. Diflucan® was limited to 2 tablets per dispensing and the percent benefit reflects the calculations based on 2 tablets. Patients with the Cigna plan were required to pay the total charge of their Ortho Tri-Cyclen® as well as the 2 tablets allowed for Diflucan® and therefore the benefit was 0, however this was not calculated into the average percent benefit. The average benefit to female patients with Cigna Health plans drops to 33.9% when the 0% benefits are included. The Blue Advantage plan required patients to pay the total charge of their Propecia®, Diflucan®, and Premarin ® therefore, these prescriptions had a zero percent benefit and was not calculated into the average percent benefit. Only 4 Viagra® tablets were allowed per month and only 4 Muse® suppositories were covered. If the prescriptions that had a zero percent benefit were included in the average, the average benefit for women becomes 25.5% and the benefit for men Conclusion
This study shows there is significant variability between different health plans and how much benefit they provide to their patients. It also indicates that these benefits are different depending on gender. Two of the five plans examined had higher benefits for the female patients. While Cigna showed a small difference of 4.2% between the genders, Partners had a difference of 10.2%. The other three plans included in the showed greater benefits to the male patients. United Healthcare showed benefits that were 1.4% higher for males, which was the most fair according to this study. NC Medicaid had a 2.1% difference in favor of male patients. State Teacher’s and Employees was 14.8% different between the genders favoring the males. Blue Advantage was 25.5% different between the If the medications which were included by the plans but provided a 0% benefit to the patients were included, only Partners provides its female patients with a greater benefit than its male patients. There is an 18.5% decrease for female patients under the Cigna plan, a 12.9% decrease for females with United Healthcare, and a 24.9% disadvantage to State Employee covered females. Male patients have a 7.7% decrease and female patients have a 38.3% decrease for the Acknowledgments
Deborah Ross, House of Representatives, NC General Assembly, Rebecca W. Chater, RPh, MPH, FAPhA, Betty H. Dennis, BS, MS, PhramD References
www.ncga.state.nc.us
www.Viagra.com-
www.Propecia.com
www.vivus.com
www.flomax-bph.com
www.androderm.com
www.diflucan.com
www.who.int
www.nolvadex.com
www.ortho-mcneil.com
Disclaimer

The text in this article is that of the author’s alone. This material is not a
resolution, position or statement of the North Carolina Board of Pharmacy.
Reprint Address
Anna C. Naples
24 Warbler Lane
Durham, NC 27712
Not covered Not covered Not covered Not covered 52.4
61.9
58.9
65.6
95.5 50.35
40.3**
93.4 63.8
45.9** 40.66**
Benefit Comparisons
Table 1. Percent benefits by health plan, averages by gender included excluding
0% benefits. * This means that 84.9% of the total charge was paid by the Health
Plan ** Average including 0% benefits.

Source: http://www.ncbop.org/about/Student%20Projects/GenderDetrimentsInHealthPlanBenefits.pdf