Insurers End Coverage for Key Drugs

Insurance is ending coverage for some key drugs that affect the health of patients. It’s a David-vs.-Goliath dispute, and millions of patients are caught in the middle — perhaps even unaware they’re about to lose coverage for compounded medications they need for their conditions. Insurers End Coverage for Key Drugs
At issue are the customized medications pharmacists prepare for patients who can’t metabolize or tolerate commercial drugs. Compounded medicines often are the only option for doctors treating certain children and seniors, patients coping with the pain of cancer and diabetes, and those with liver or kidney diseases.
In one corner: powerful insurance companies and pharmacy benefit managers (PBMs) hell-bent on saving money by eliminating or cutting coverage of those medications.
In the other corner, fighting to reverse their moves: a coalition of patients, physicians, pharmacists and pro-patient groups like the Veterans Advocacy Group of America, the Kidney Cancer Association and the Arthritis Foundation.
“This is about shifting costs to patients,” says Jay McEniry, executive director of Patients and Physicians for Rx Access (saverxaccess.org). “Physicians are being placed in the impossible position of either prescribing a compounded medication the patient needs but can’t afford, or prescribing a less effective treatment because it may be covered by the patient’s insurance.”
The list of “Goliaths” who’ve announced or already implemented such cutbacks now includes United Healthcare/Optum Rx, Catamaran, CVS/Caremark, Harvard Pilgrim and Blue Cross Blue Shield plans in several states.
But the coalition’s immediate wrath is directed at the nation’s largest PBM: Express Scripts, which in September is slated to stop covering 1,000 drug ingredients commonly found in compounded medications — effectively “eliminating an entire class of medications,” says McEniry.
Express Scripts and others argue that commercial drugs can do the job just as well for less money. But try telling that to patients like Linda Sauer.
The Dwight, Illinois, woman relies on her doctor-prescribed compounded medications for relief from several painful and debilitating conditions, and is outraged that Express Scripts’ decision leaves her no choice but to pay for them out of pocket.
“They’re denying me access to medicines that work better than the mass-produced drugs I’ve tried,” she says. “It will cost me and others hundreds of dollars per month.”
Sauer at least has read the advisory notice from Express Scripts, which the coalition claims gives “misleading reasons” for targeting what it calls “essential medicines” whose ingredients are purchased from FDA-regulated suppliers. But what of patients who didn’t?
Sadly, they’re in for a shock the next time they try to fill a prescription.