A New Form of Insurance Denial of Coverage

Doctors hate the first of the year. Besides the cold weather, there are a myriad of reasons for that. In private practice one typically goes without a paycheck for two months. That’s a bit of a stressor. Increasingly more frustrating every year is all the changes from pharmacy benefit managers. Finally the physician finds the right combination of antihypertensive drugs, blood pressure is well controlled, life is good! Then the dreaded letter from the pharmacy benefits company arrives, stating that Exforge (or Metoprolol ER or…) is not covered under the patient’s insurance plan. For some reason this year it is extended release medications on seniors’  plans that are not covered, generic no less. The elderly patient, who may be challenged in regard to compliance, now must take his or her medicine two or three times a day instead of just once. No problem, I’m sure the insurance company will send out a nurse to make certain that the patient takes all medications properly. No wait, the nurse is busy sending the patient to the emergency room for a hangnail because she’s worried that pain in the left arm is cardiac. But I digress.

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Copy from denial letter

This week a new level of denial has been breached. Now medications are deemed “experimental”. Somehow pharmacy benefit managers have confused off-label with experimental. Why would they do that? Simple: off-label use isn’t excluded on a patient’s insurance but experimental is. In one particular case my patient has a progressive debilitating neurologic disease that is causing pain. The patient already has issues with constipation due to an inability to be mobile so narcotics are not a good option, not to mention that he does not want to be dependent on narcotics for this pain. Amazingly this “experimental” medication was doing a  good job of managing the pain for the last year or so.

Not only is the denial of this medication arbitrary and cruel, it is unethical. Off label use of medications is an accepted and necessary treatment choice, particularly with pain, where avoiding narcotics is important for patient quality-of-life and many off-label use of medications is well-studied but not in the drug’s package insert since the medication has long been generic. In the meantime the patient asks ME how to deal with the issue. I recommended that they call their insurance company to begin an appeal process. Frankly a good lawyer might be a good idea as well.

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Nostalgia and the Local Pharmacy

Recently a patient in our practice requested his Plavix renewal from a 90-day mail order pharmacy. When the “estimated” price came to $585 he decided to stop taking his cardiac medication. In exploring his insurance website I found that the actual cost would only be $200. In addition the company had a “Do Not Substitute” order on the prescription (something his cardiologist denies writing) and the cost of the generic is $28.59. Wow–the drug he almost quit taking because of the website price estimation was, in reality, 96% cheaper than originally thought.

Contrast this with a phone call I received recently from Wish’s Drugs, a local pharmacy here in Louisville. The pharmacist paged me on a Saturday morning regarding a patient’s medication. I called the pharmacy and the pharmacist answered the phone(!). He suggested that my patient get a similar drug for half the cost of what I prescribed and asked if that would be OK. When I hung up the phone it struck me how pleasant that had been. Not just that the pharmacist was looking out for the interest of our mutual patient, but the call from start to finish–a real person answered the phone and it was the person I needed to speak to. Not only did I not push three different buttons and listen to three different voice messages along with a sales pitch for flu shots, but I immediately spoke to a person knowledgable and caring about my patient and her medical condition. Contrast THAT with the 90 day site where the patient, unknowing, was supposed to go back to his insurance web site, check the price of his medication and THEN go back to the pharmacy web site and decide that he could actually afford the medication because the real price to him would (only) be $200. No friendly pharmacist in that other state willing to make a phone call and get his patient a better deal on his medicine.

It’s not that I think mail order pharmacies are inherently evil, it’s just that the service component is reduced to the patient. However, interestingly enough, the two studies I read regarding mail-order vs. local pharmacies [1,2] found patients are more compliant when they use mail order. Perhaps this is because when medicines are delivered right to the patient’s door it reduces extra steps, making it easier for patients to remember and obtain their drugs?

In my experience patients enjoy the convenience and economy of getting 90 days worth of medication delivered to their mailbox but when there is a problem they are quickly frustrated by the difficulty of explaining to someone in another state what their needs are. As a physician, I am annoyed with the same difficulties, plus the frequent faxes asking about changing patients to a “cost-savings” alternative, something the patient is usually unaware of so we have to call him/her, ask their permission, explain what the change entails, etc. Just one more thing in my over-extended day that I don’t have time for.

Mail order pharmacies are not going away and local pharmacies where the pharmacist knows the patient and cares for him/her in a more intimate way are disappearing into distant, nostalgic memories. Given the studies quoted here, maybe that’s a good thing. Does my desire for it to be different, for every patient to have the individual attention of the good pharmacist at Wish’s make me out-dated?
1. Schmittdiel JA. The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users.J Gen Intern Med. 2011 Dec;26(12):1396-402. Epub 2011 Jul 20
2. Duru OK. Mail-order pharmacy use and adherence to diabetes-related medications. Am J Manag Care. 2010 Jan;16(1):33-40

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