Access to medication has become an all-too-common challenge for patients with one of the country’s most common diseases: diabetes.
Several health plans announced in late 2016 that they would drop certain insulin products from coverage, leaving patients scrambling. Now, high out-of-pocket costs have led a handful of patients to target pharmaceutical manufacturers in a new lawsuit over insulin. Both events point to a troubling reality – regular access to medication is no longer a given for diabetes patients.
Formulary Exclusions
Formulary exclusions such as those made by CVS Caremark and Express Scripts for 2017 intend to drive patients toward a medication that’s less expensive for the insurance company. Part of a broader phenomenon known as “non-medical switching,” these changes often originate with pharmacy benefit managers, which handle prescription drug coverage for health plans.
But a lower price for the pharmacy benefit manager doesn’t always equate to lower out-of-pocket costs for patients. To secure a spot on approved drug lists, pharmaceutical companies routinely offer pharmacy benefit managers a rebate on the list price of a given drug. How much of the savings funnels from health plans to patients remains unclear because the negotiations happen behind closed doors. Thus, some diabetes patients continue to battle high co-pays, even in the face of deepening discounts from manufacturers.
Non-Medical Switching
What patients and health care providers do know is that formulary exclusions and other forms of non-medical switching present real challenges for diabetes patients.
Similar insulin and oral diabetes medications may share a common indication from the FDA, but they are not identical products. They may, for example, vary with regard to dosing, injectable device or instructions of use.
When driven by health plan design to switch from one product to another, patients must restart their search for the right dose and medication regimen. Worries about hypoglycemic events may arise for patients who have not fully stabilized their AIC, an indicator of blood glucose control.
Meanwhile, the time and co-pays for doctor’s visits, lab work and new medications add up. In fact, they may overshadow any savings expected from switching to a less expensive drug. Complications can impact work, personal life and social activities as well.
Formulary exclusions and other forms of non-medical switching may provide cost savings for health plans. But they extend no such promise to patients with diabetes, who could instead receive a one-size-fits all treatment regimen fueled by health plans’ financial considerations rather than personal health needs.
