Well being-care large Cigna, which sells insurance coverage and owns pharmacy profit supervisor Specific Scripts, eliminated Cosentyx from virtually all of its formularies – the lists of medicine it covers.
Whereas such non-medical switching has change into more and more widespread within the PBM/medical insurance world, this time Cigna went a step additional than different firms – providing clients a $500 debit card to vary to one of many medication it prefers.
The transfer by the $168 billion firm based mostly in Connecticut sparked outrage amongst affected person advocates.
“This non-medical recommendation, paired with a monetary incentive for the categorical objective of shifting a steady affected person to a distinct drug, circumvents shared decision-making within the provider-patient relationship and undermines the physician’s recommendation on what medicines and coverings are greatest,” mentioned an April 16 missive to Cigna’s chief medical officer from greater than 5 dozen teams.
“Focusing on sufferers and attractive them with a monetary incentive, notably throughout a pandemic – the place funds and employment for a lot of are unsure and sufferers taking Cosentyx are already experiencing heightened worry of significant sickness or dying – makes this letter not solely unethical, however unconscionable.”
Specific Scripts additionally eliminated Novartis-sold Cosentyx from its nationwide drug formulary and changed it with Taltz, one other biologic (genetically engineered) drug usually offered for roughly the identical worth by Eli Lilly. Nonetheless, the PBM didn’t supply any direct monetary incentive for making the swap.
The American Journal of Managed Care noticed a replica of the Cigna letter. Sufferers would not get the $500 card till six to eight weeks after they each fill a first prescription earlier than Aug. 31 and a second earlier than Dec. 31.
Cigna informed the Journal that its members have been “supplied a number of different medicines which are equally efficient and extra reasonably priced. In uncommon events when a affected person isn’t ready to make use of the popular possibility, we advocate that our shoppers supply an environment friendly overview course of to help these sufferers in acquiring a non-formulary treatment in these cases.”
However the affected person advocates famous that among the options to Cosentyx beneficial by Cigna don’t carry out the identical perform.
That occurs regularly when PBMs and well being insurers set their new formularies, mentioned Dr. Madelaine A. Feldman, president of the Coalition of State Rheumatology Organizations and a medical assistant professor of medication at Tulane College College of Medication in New Orleans.
She cited a number of examples from the PBMs’ 2021 formulary exclusions.
CVS Caremark excluded at the least six biologic medication used to deal with an autoimmune illness like rheumatology, together with three biosimilar medication that usually are cheaper, plus one other usually thought to be the most secure for ladies of child-bearing age, she mentioned.
The three remaining medication on the CVS formulary, all manufactured by Johnson & Johnson’s pharmaceutical arm Janssen, consists of one not usually used to deal with rheumatoid arthritis however relatively psoriatic and inflammatory bowel illnesses. All belong to a particular class of drug generally known as TNF inhibitors, designed to cease irritation attributable to an extra of a substance known as tumor necrosis issue (TNF) generated by the human physique.
“So for a affected person with rheumatoid arthritis that does not reply to TNF inhibitors and must have a physician-administered treatment – for any variety of causes – there are not any different (medication) to select from,” Feldman mentioned.
Critics of the rising variety of medication excluded from formularies say the tactic relies extra on cash than drugs. The PBMs say they save customers cash by providing related medicines at decrease costs.
Joshua Cohen, an impartial health-care analyst, wrote final yr in Forbes journal, “There’s proof to counsel that a variety of more cost effective prescribed drugs in sure therapeutic courses are generally being excluded by PBMs, whereas much less cost-effective medicines are beneficial.”
For instance, the 2020 formulary of Specific Scripts excluded lower-priced, licensed generic variations of hepatitis C medicines Harvoni and Epclusa, Cohen wrote. On the similar time, rival PBM CVS Caremark left cheaper medication Mavyret and Zepatier off its checklist however included the more-expensive model title variations of Harvoni and Epclusa. The formulary did not point out the cheaper variations of those medication.
Is the drug you are taking on a pharmacy profit supervisor’s formulary exclusion checklist? In that case, your medical insurance would possibly now not cowl it, even when the treatment has been serving to you for years.
Listed here are hyperlinks to the highest three PBMs’ lists of medicine they advocate not being coated by insurance coverage:
Specific Scripts: express-scripts.com/art/pdf/NPF_Preferred_Formulary_Exclusions2021.pdf