Journal of Applied Pharmacy
Open Access

The Role of Health Insurance in Pharmaceutical Care and Medication Access

Sienna Everly^{* *}Correspondence: Sienna Everly, Department of Pharmaceutical Care, University of Alberta, Alberta, Canada, Email:

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Description

Health insurance plays an essential role in ensuring that individuals have access to necessary medical treatments, including medications. As pharmaceutical costs rise globally, the intersection between health insurance and pharmacy has become increasingly important in determining how patients can afford and access prescription drugs. The relationship between health insurance providers and pharmacies influences drug availability, costs, and the overall health care experience for patients. The role of health insurance in pharmacy access, medication affordability, and the challenges that individuals and healthcare providers face in ensuring patients receive the right medications.

Health insurance is designed to reduce the financial burden of medical costs, including those related to prescriptions. Under most insurance plans, prescription medications are covered to varying degrees, but the extent of coverage depends on the specifics of the insurance plan. When individuals need medications, insurance can make the difference between whether they are able to afford their prescriptions or go without necessary treatment. Health insurance plans typically divide medications into different tiers based on cost. The lower the tier, the less expensive the medication. Commonly, generic medications fall under the lowest tier, while brand-name drugs or specialty medications, such as biologics, can fall into higher tiers with higher out-of-pocket costs. By using these tiered systems, insurance companies attempt to manage costs while still providing access to necessary medications.

Many insurance plans also have formularies, which are lists of covered drugs. Formularies are used to control drug costs and often encourage the use of more affordable or generic medications. For example, if a patient is prescribed a medication that is not on the formulary, they may have to pay a higher copay or even the full price of the drug, making it less affordable. In some cases, insurance companies may require prior authorization before covering certain medications, which can delay treatment and add administrative burdens for both patients and healthcare providers.

Pharmacists plays an important role in connecting health insurance with access to pharmacy services. They are the professionals who interact directly with patients, guiding them on how to fill prescriptions, use medications safely and navigate the complexities of insurance coverage. Pharmacists can help patients understand their insurance coverage, explain formularies and identify cost-saving strategies, such as suggesting generic alternatives to brand-name drugs.

In many cases, pharmacists may also work with healthcare providers and insurance companies to secure prior authorizations or find alternative medications that are more affordable for the patient. Pharmacists can also monitor for drug interactions and ensure that patients are not prescribed medications that could pose risks, given their existing health conditions or other medications. Additionally, pharmacists help patients understand the importance of adherence to prescribed regimens. Medication nonadherence is a major issue in healthcare and pharmacists are often the first line of defense in counselling patients about the long-term benefits of taking medications as prescribed, including preventing disease progression and reducing hospital admissions.

While health insurance plays an essential role in medication access, several challenges exist in the current system, especially concerning the rising cost of drugs. These challenges include: The prices of prescription medications have increased dramatically in recent years, making it more difficult for patients to afford the medications they need. Specialty drugs, such as those used for cancer treatment, biologics, or autoimmune diseases, can cost thousands of dollars per month, which many insurance plans do not fully cover. Even patients with insurance may struggle to pay their share. Global supply chain issues, manufacturing disruptions, and the high cost of certain drugs can lead to shortages of vital medications, leaving patients without access to essential treatments. Pharmacies and health insurance plans must work together to manage these shortages and find alternative solutions for patients in need.

The intersection between health insurance and pharmacy is a complex but important part of modern healthcare. Insurance plans help manage the cost of medications, but rising drug prices, formularies and co-payments can still present barriers for many patients. Pharmacists serve as an invaluable resource in helping patients navigate the complexities of insurance coverage and medication access, ensuring they get the medications they need for optimal health. However, addressing the challenges of high drug costs, medication nonadherence and administrative hurdles requires ongoing collaboration between healthcare providers, insurers and policymakers to ensure that medications remain accessible and affordable for all patients.