When insurers cut diabetes coverage

Children with diabetes face a lifetime of challenges. If insurers continue to exclude more and more diabetes-related medications and supplies from coverage, those children and their families could be saddled with a lifetime of exorbitant out-of-pocket costs as well.

The rate of diabetes has steadily increased in Tennessee. Nearly 13 percent of Tennesseans have been diagnosed with the disease, making Tennessee’s rate of diabetes the seventh highest among all states.

The growing incidence of diabetes may be one reason pharmacy benefit managers (PBMs) – private companies health plans hire to oversee their prescription drug benefits – exclude diabetes-related medications and supplies from coverage, more than any other treatment category, according to a study by the Doctor-Patient Rights Project.

In the past four years, the number of diabetes-related medications or supplies excluded from coverage by the nation’s two largest PBMs (CVS and Express Scripts) has increased by almost 80 percent, the only treatment category where the PBMs increased the number of excluded medicines every year.

Diabetes-related treatments now account for one out of every five medicines excluded from coverage by these PBMs.

PBMs employ formulary exclusion lists to compel patients to use less expensive treatment choices, falsely assuming that every patient with diabetes will respond the same way.

DPRP found that many patients who are asked to switch to a new medication choose to pay out-of-pocket for the treatment their doctor originally prescribed, rather than switch to the insurer’s preferred drug.

In effect, formulary exclusions transfer more of the cost of prescribed treatments to patients and their families.

Studies show that patients forced to shoulder more of the expense of their medications are more likely to try to make the prescriptions for their original medication last longer by splitting pills or skipping doses of insulin.

People with diabetes who do not experience immediate symptoms from not following proper treatment protocols may wrongly conclude that the medicine remains just as effective.

This is especially true of low-income and minority patients, already more likely to develop diabetes and to experience diabetes-related organ failure.

Every parent wants the best for their child. Insurers that refuse to cover certain prescribed diabetes treatments thinking that parents will simply switch to the insurer’s cheaper alternative may be gravely mistaken.

Forced non-medical switching may simply increase out-of-pocket expenses for parents and, as a result, increase the lifetime treatment costs for their children with diabetes.

Reduced adherence accounts for up to 10 percent of hospitalizations, 25 percent of nursing home admissions and as many as 125,000 premature deaths annually, according to a study in the Journal of Managed Care & Specialty Pharmacy. As a result, it contributes an extra $100 billion to $289 billion in medical expenses each year, at least some of which fall to insurers to pay.

Jeff Hitchcock is founder and president of Children with Diabetes. Stewart Perry is past board chairman of the American Diabetes Association.