A front-page article April 26 and a Health section article March 25 reported that many health insurance companies withdrew or dropped coverage of the prescription allergy drugs Allegra and Zyrtec after Claritin became available over the counter in December. While some health insurers have increased the co-payments consumers must pay for Allegra and Zyrtec or have made it more difficult for patients to obtain coverage for the two drugs, insurers at this point have not withdrawn or dropped coverage entirely for the prescription medications. (Published 5/14/03)

If you don't start thinking about your spring allergy options until the forsythia blooms, brace yourself for big changes. The once-familiar remedy landscape is looking very different since the Food and Drug Administration (FDA) last December okayed over-the-counter sales of Claritin (loratadine), formerly the best-selling prescription allergy drug.

While that makes the antihistamine accessible without a call or visit to the doctor, there's a significant downside: Since insurers don't cover the cost of over-the-counter drugs, that puts the roughly $1-per-pill cost of Claritin squarely in your tissue-laden pocket. Multiplied by six months, the time frame for spring, summer and fall allergies, that's $180 -- or the cost of a night at a nice hotel this summer. For people with prescription drug coverage, that's $30 to $120 more than last year's bill, depending on whether your co-pay then was a standard $10 or $25.

That's not all: Once the FDA changed Claritin's status, many insurers, following the lead of WellPoint Health Networks, shrank or withdrew coverage for the entire class of non-sedating antihistamines to which Claritin belongs. The class includes Clarinex (Claritin's successor), Zyrtec and Allegra -- all still prescription-only drugs. Robert Seidman, chief pharmacy officer at WellPoint, estimates the carrier stands to save $90 million a year by shifting the cost of these drugs to patients.

Consumers who insist on sticking to such favorites could see $120 to $240 added to last year's allergy relief bill -- whether you pay cash or a co-pay. But for those more flexible, experts say the upheaval in the allergy pill landscape may not be all bad news. The change could also be an opportunity to have your physician evaluate your allergy treatment plan to make sure it's as effective as possible.

"Now that patients are using cost as a reason to look at other options, there could well be other drugs that are not only covered by insurance, but are more effective in preventing or treating symptoms," says Ed Berger, president of the American College of Allergy, Asthma and Immunology.

That's another way of saying that for all of Claritin's heavy promotion (its maker, Schering-Plough, spent at least tens of millions in direct-to-consumer advertising of the product in the 10 years it was a prescription drug), there have long been questions about its effectiveness.

According to Lisa Frawley, a drug analyst in the market research firm DataMonitor, it's most effective in treating the 80 percent of allergy patients with mild to moderate symptoms. People with more severe allergies, she says, often had less success with the drug.

Here's an overview of the options for treating spring allergies:

Loratadine

If loratadine (the compound sold under the brand names Claritin and Alavert) has been effective for you in the past, allergists recommend sticking with it.

Claritin and Alavert both cost about $1 per pill, though some insurers, doctors and pharmacists may have discount coupons for as much as $10 off a package of 30 pills, and buying packages of 20 to 48 pills can cut costs somewhat.

Also, Washington area stores including CVS, Target and RiteAid often offer a few dollars off for people who cut coupons from the Sunday circulars. Generic versions cost less. A 30-count package of CVS loratadine costs $18.99, or about 60 cents per pill.

Check the label, though, before heading for the checkout counter. Like their prescription predecessor, some versions of loratadine come with a decongestant to help clear stuffy noses. This means the product may also come with additional side effects, such as dry mouth and, sometimes, sleeplessness, agitation or nervousness, says Mark Dykewicz, chair of the FDA's pulmonary-allergy drugs advisory committee. If you don't need the decongestant, better to hunt for plain loratadine.

Other Non-Sedating

Other non-sedating antihistamines such as Allegra and Clarinex (Claritin's prescription successor) may bring some patients greater relief than Claritin. The same goes for Zyrtec, also in this category, although this drug can be somewhat more sedating. Whether any of these products is easier on the wallet may depend on your insurer.

Aetna and Cigna, for example, both of which insure and administer company-paid insurance for millions in the Washington area, have moved Clarinex, Zyrtec and Allegra from the second co-pay tier to the more expensive third tier for 2003. So while last year their members likely paid $10 to $20 for one of these drugs, this year the co-pay is more likely to be $40 to $50. (Co-pays can differ depending on the type of plan your company offers.) That means that a six-month supply of any of the drugs could run patients as much as $300 instead of the $60 to $120 they paid in previous years.

No numbers exist yet on how many insurers have reduced coverage for the drugs, but the shift is significant enough for the American Academy of Allergy, Asthma and Immunology (AAAAI) to have issued a statement protesting the move.

Cost isn't the only barrier between consumers and these drugs. Some carriers, such as Cigna, Aetna and CareFirst, will also require your doctor to call and authorize your use of the prescription non-sedating antihistamines. The doctor may have to prove that other drugs, including Claritin, are ineffective for you.

If you've been a Claritin user and your insurer will cover other options, ask your doctor for samples so you can test them before having to spring for a hefty co-pay.

Nasal Steroids

A good alternative (maybe even a better one, says Dykewicz) can be nasal steroid drugs such as Flonase and Nasonex. Within a few weeks, these product names will likely be more familiar.

Manufacturers such as GlaxoSmithKline and Schering Plough are touting their products widely in newspaper and TV ads, hoping they can draw some former non-sedating antihistamine users since the sprays are more likely to be covered by insurance.

Intranasal steroid sprays reduce the underlying inflammation associated with allergies and reduce the number of cells that contain histamines, chemicals that cause sneezing, itching and runny nose, says Harold S. Nelson, senior staff physician in the department of medicine at the National Jewish Medical and Research Center. The sprays, he says, become most effective after they're taken regularly for a week. Because they also relieve congestion, they could reduce your need for a decongestant, with its accompanying side effects.

Another advantage: Nasal steroids are effective even after symptoms have begun. (Oral antihistamines often have to be started before spring allergy season, if you can figure out when that is, to be most effective.)

However, the sprays have some disadvantages as well, including having to squirt a liquid in your nose, which many people find uncomfortable. In some users they can cause nosebleeds. Unlike non-sedating antihistamines, they are often ineffective against itchy, swollen eyes.

Co-pays for nasal steroid sprays tend to be in the second tier, or about $10 to $30 per prescription. One canister lasts about a month. To get you to try their drugs, many of the steroid spray makers are offering a $5 rebate for each canister you buy, whether you pay a co-pay or full cost. To get a rebate coupon, go to www.nasonex.com/-/nasonex/main or http://flonase.ibreathe.com/?a=72 or search the name of the product you use to see if the company offers a rebate.

By next allergy season, the cost may be reduced, says DataMonitor's Frawley. At least one company has applied to the FDA to market a generic version of Flonase when its patent expires later this year. That could bring the co-pay down to $5 per canister for insured patients and reduce the cost significantly for people who pay for drugs out-of-pocket.

Nasal Antihistamine

If the nasal steroid sprays don't give you the same relief as your non-sedating antihistamine, Dykewicz suggests a prescription antihistamine called Astelin, which is also sprayed directly into the nose. Astelin is generally covered by insurance.

"Spraying the drug right into the nose increases the concentration of the drug and can increase relief," Dykewicz says. But the drug can also cause headaches and sedation and has a bitter taste when the spray drips down from the nasal passages.

Antihistamine Pills

Beware OTC antihistamine tablets. The most common is diphenhydramine, best known as Benadryl, which is effective but can also cause extreme drowsiness.

Another drug in this category is clemastine (Tavist). Dykewicz says studies show that even patients who take the drugs only at night have been found to have reduced concentration and residual drowsiness the next day; he recommends patients bypass the product.

"No one can be sure they can take the older antihistamines safely," he says. "A person can't assess their own sleepiness objectively. The majority of people who don't think they're having problems driving and concentrating, are."

Eye Products

One thing nose sprays may not do is relieve itchy, runny eyes, says Monica L. Monica, a spokeswoman for the American Academy of Opthalmology.

If eyes are simply red and tearing, a nonprescription decongestant eyedrop such as Naphcon or Visine may help, and costs about $4 per bottle. For itching eyes, an OTC antihistamine eyedrop such as Visine-A, Ocuhist or Naphcon-A. may work better.

\If those aren't effective, Monica recommends prescription antihistamine drops such as Patanol and Livostin, which can usually be used less frequently but cost about $60 for a month's supply.

Other options are mast cell stabilizers, such as Alomide, nonsteroidal anti-inflammatory drugs such as Acular, and a combination drug such as Zaditor.

Because there are so many different options, you may want to ask your doctor for a sample of a drug before you buy. Prescription products are likely to be covered by insurance, says Monica.

Allergy Shots

If all else fails, allergy shots, which are generally covered by insurance, could be an option. But when you consider the time you'll need to take off work or from home to get them every week or month, you'll understand why those non-sedating oral drugs became so popular. Some patients need to take shots for five to six years before they are fully effective. And for some patients, they aren't effective at all.

Some allergy sufferers may have had their interest pricked earlier this month by a Johns Hopkins study in which participants found allergy relief from just six shots in six weeks. Now, the bad news: Not only is the treatment still experimental; it's aimed at severe ragweed allergy -- not something that comes into play here this time of year.

Better Luck Next Year

By the time the buds start to bloom next spring, better treatment news could be in the air, say DataMonitor's Frawley. Look for approval of Xolair, the first of an entirely new class of drugs, which is expected to be effective in patients with severe spring allergies. At that point, you might almost find yourself wishing for an extra sneeze or two.

Even the most tightwad insurers tend to cover at least some of the cost of novel therapies.

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Francesca Lunzer Kritz is a regular contributor to the Health section.