Sorry for this problem but I think you are seeking to place blame where it does not belong - there are ways that this could have been handled - but most likely a more expensive way.
PBM and the insurers aren't making health decisions - They are working within the confines of the Medicare Part D program. They are working under the confines of the Medicare Part D program to help save ALL of us money without sacrificing health. They are working in a financial manner - only the doctor can change the medication via a new Rx.
Your husband has the right to appeal - that is a Medicare rule - that‘s his solution per the Medicare Part D program. However, I think you need some evidence that Invokana was on the 2021 formulary when he signed up for the program. When he was notified of the change and WHY the change was made. Did they give him the WHY in the notification of this change?
In this class of drugs - Medicare Part D law is that the plans only have to cover at least (2) - seems there are even more than (2) - they don’t have to cover every med in this class of medication. Unless there is a safety issue confirmed by the FDA, then if a particular med is not available under one insurers plan, it will be under another insurers plan that is available to you -
The FDA requested in 2013 that Invokana have a black box warning put on it. The drug company failed to put it on until 2017. The risk is because of an increase chance of amputation but the FDA reevaluated it in 2020 and removed the black box warning criteria with a caveat that the amputation risk is still there. That (4) year delay created lawsuits - and with lawsuits come increase in drug price.
Since you haven't given the name of the type policy you have or area - it is hard to help you verify the info. However, I looked up the AARP (UHC) MedicareRx Preferred (PDP) for my area and pulled up the 2021 formulary.
1. This formulary was LAST UPDATED on 02/01/2021 - so we know something has changed since it was issued - but what, I have no idea; it is not my plan.
2. Invokana is NOT listed on this formulary at all
3. Jardiance is listed as a Tier 3 with QL - that is the drug that UHC (commercial policies) shows as their lower cost option with their 2021 changes: https://www.uhc.com/content/dam/uhcdotcom/en/Pharmacy/PDFs/Traditional-3-Tier-PDL-UPDATE-Eff-Jan-1-2...
Your husband could have filed an exception with the doctors help - because this “exception” request is available to your husband under the Medicare PDP rules - that is how you have to handle it.
This is from Medicare -
Medicare.gov - Your Guide to Medicare Prescription Drug Coverage
A Medicare drug plan can make some changes to its drug list during the year if it follows guidelines set by Medicare. Your plan may change its drug list during the year because drug therapies change, new drugs are released, or new medical information becomes available. Plans may immediately remove drugs from their formularies after the Food and Drug Administration (FDA) considers them unsafe or if their manufacturer removes them from the market. Plans meeting certain requirements also can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs. If you’re currently taking any of these drugs, you’ll get information about the specific changes made afterwards.
For other changes involving a drug you’re currently taking that will affect you during the year, your plan must do one of these:
■ Give you written notice at least 30 days before the date the change becomes effective; or
■ At the time you request a refill, provide written notice of the change and at least a month’s supply of the drug under the same plan rules as before the change. You may need to change the drug you use or pay more for it. You can also ask for an exception (see page 78).
Generally, using drugs on your plan’s formulary will save you money. If you use a drug not on your plan’s drug list, you’ll have to pay full price, instead of a copayment or coinsurance, unless you qualify for a formulary exception. All Medicare drug plans have negotiated to get lower prices for the drugs on their drug lists, so using those drugs will generally save you money. Also, using generics instead of brand-name drugs may save you money.
What if my plan won’t cover a drug I need?
If your Medicare drug plan won’t cover a drug you think should be covered, or it will cover the drug at a higher cost than you think you should have to pay, you have these options:
1 . Talk to your prescriber (the professional who wrote your prescription)
Ask your prescriber if you meet prior authorization or step therapy requirements. Contact your plan for more information on these requirements. You can also ask your prescriber if there are generic, over-the-counter, or less expensive brand-name drugs that could work just as well as the ones you’re taking now
2 . Request a coverage determination (including an “exception”) .You, your representative, your doctor, or other prescriber can request (orally or in writing) that your plan cover the drug you need. You can request a coverage determination if your pharmacist or plan tells you one of these: ■ A drug you believe should be covered isn’t covered. ■ A drug is covered at a higher cost than you think you should have to pay. ■ You have to meet a plan coverage rule (like prior authorization) before you can get the drug you requested. ■ It won’t cover a drug on the formulary because the plan believes you don’t need the drug.
You, your representative, your doctor, or other prescriber can request a coverage determination called an “exception” if:
■ You think your plan should cover a drug that’s not on its formulary (drug list) because the other treatment options on your plan’s formulary won’t work for you.
■ Your doctor or other prescriber believes you can’t meet one of your plan’s coverage rules, like prior authorization, step therapy, or quantity or dosage limits.
■ You think your plan should charge a lower amount for a drug you’re taking on a higher-cost drug tier because the other treatment options in your plan’s lower-cost drug tier(s) won’t work for you.
f you request an exception, your doctor or other prescriber will need to give a supporting statement to your plan explaining why you need the drug you’re requesting. Check with your plan to find out if the supporting statement is required to be made in writing. The plan’s decision-making time period begins once your plan gets the supporting statement. You can either request a coverage determination before you pay for or get your drug, or you can decide to pay for the drug, save your receipt, and request that the plan pay you back by requesting a coverage determination.
It's Always Something . . . . Roseanna Roseannadanna