Insurance Coverage

Background

Health insurance plans traditionally cover prescribed medications approved for treating diagnosed medical conditions, with patients paying a portion of costs through copays or coinsurance. However, essential over-the-counter treatments for common illnesses and symptoms have generally been excluded from coverage, leaving consumers to pay full retail prices out-of-pocket. These costs add up, leading some patients to forgo beneficial but expensive OTC remedies.

The Issue

Recently, policy experts have proposed that insurers should expand formulary lists to include select over-the-counter medicines that can effectively and safely treat minor ailments or supplement prescription regimens while lowering overall expenditures. Opioid alternatives for pain relief, acetylsalicylic acid to reduce cardiovascular risks, and antihistamines for mild allergies present prime opportunities.

CHPA’s Position

Providing coverage for clinically-validated, over-the-counter products capable of preventing complications or replacing higher cost prescriptions through flexible spending arrangements aligns with value-based models working to improve access and outcomes across populations. Although adding benefits requires adjusting contracts and reimbursement rates, supporting the prudent use of affordable frontline healthcare options helps patients and the system.