Drugs you need might not still be covered
If you take Cosentyx, you already might have discovered that your health insurance might no longer cover the injection used to treat the skin disorder psoriasis.
Health-care giant Cigna, which sells insurance and owns pharmacy benefit manager Express Scripts, removed Cosentyx from almost all of its formularies – the lists of drugs it covers.
While such non-medical switching has become increasingly common in the Pbm/health insurance world, this time Cigna went a step further than other companies – offering customers a $500 debit card to change to one of the drugs it prefers.
The move by the $168 billion company based in Connecticut sparked outrage among patient advocates.
“This non-medical advice, paired with a financial incentive for the express purpose of moving a stable patient to a different drug, circumvents shared decision-making in the provider-patient relationship and undermines the doctor’s advice on what medicines and treatments are best,” said an April 16 missive to Cigna’s chief medical officer from more than five dozen groups.
“Targeting patients and enticing them with a financial incentive, particularly during a pandemic – where finances and employment for many are uncertain and patients taking Cosentyx are already experiencing heightened fear of serious illness or death – makes
this letter not only unethical, but unconscionable.”
Express Scripts also removed Novartis-sold Cosentyx from its national drug formulary and replaced it with Taltz, another biologic (genetically engineered) drug typically sold for roughly the same price by Eli Lilly. However, the PBM did not offer any direct financial incentive for making the switch.
The American Journal of Managed Care saw a copy of the Cigna letter. Patients wouldn’t get the $500 card until six to eight weeks after they both fill a first prescription before Aug. 31 and a second before Dec. 31.
Cigna told the Journal that its members were “offered several alternative medications that are equally effective and more affordable. In rare occasions when a patient is not able to use the preferred option, we recommend that our clients offer an efficient review process to assist those patients in obtaining a non-formulary medication in these instances.”
But the patient advocates noted that some of the alternatives to Cosentyx
recommended by Cigna do not perform the same function.
That happens frequently when PBMS and health insurers set their new formularies, said Dr. Madelaine A. Feldman, president of the Coalition of State Rheumatology Organizations and a clinical assistant professor of medicine at Tulane University School of Medicine in New Orleans.
She cited several examples from the PBMS’ 2021 formulary exclusions.
CVS Caremark excluded at least six biologic drugs used to treat an autoimmune disease like rheumatology, including three biosimilar drugs that typically are cheaper, plus another generally regarded as the safest for women of childbearing age, she said.
The three remaining drugs on the CVS formulary, all manufactured by Johnson & Johnson’s pharmaceutical arm Janssen, includes one not typically used to treat rheumatoid arthritis but rather psoriatic and inflammatory bowel diseases. All belong to a special class of drug known as TNF inhibitors, designed to stop inflammation caused by an excess of a substance called tumor necrosis factor (TNF) generated by the human body.
“So for a patient with rheumatoid arthritis that doesn’t respond to TNF inhibitors and needs to have a physicianadministered medication – for any number of reasons – there are no other (drugs) to choose from,” Feldman said.
Critics of the growing number of drugs excluded from formularies say the tactic is based more on money than medicine. The PBMS say they save consumers money by offering similar medications at lower prices.
Joshua Cohen, an independent health-care analyst, wrote last year in Forbes magazine, “There is evidence to suggest that a number of more cost-effective pharmaceuticals in certain therapeutic classes are sometimes being excluded by PBMS, while less cost-effective medicines are recommended.”
For example, the 2020 formulary of Express Scripts excluded lower-priced, authorized generic versions of hepatitis C medications Harvoni and Epclusa, Cohen wrote. At the same time, rival PBM CVS Caremark left cheaper drugs Mavyret and Zepatier off its list but included the more-expensive brand name versions of Harvoni and Epclusa. The formulary didn’t mention the cheaper versions of these drugs.
Is the drug you’re taking on a pharmacy benefit manager’s formulary exclusion list? If so, your health insurance might no longer cover it, even if the medication has been helping you for years. drowland@dispatch.com @darreldrowland