NON-MEDICAL SWITCHING DRUGS

[RKSK359581]

Where is on the issue of non-medical switching of drugs and increasing co-pays?  My husband and I have been with AARPUnitedHealthCare Part D since 2007.  Suddenly, they have started refusing to cover stable medications and are demanding that we switch to other medications.  My husband has been doing well on Invokana for his type 2 diabetes and his doctor is very pleased with how this medication has worked for him.  Now, UHC wants to switch him to another medication that he had tried earlier that did not work as well.  The primary reason seems to be that by switching the med, they increase the co-pay to 4x what the Invokana co-pay was. 

I am encountering the same issue with a med that my dermatologist wants me on.  UHC is refusing to cover the med, instead wanting to require me to do injections at the Dr's office every week.  Surely this is not cost-effective!

Obviously, they make these switches immediately after the closure of the period when one can change plans, so that the client has few options for nearly a year.  Perhaps AARP should pull their sponsorship from UHC?

[AlisonB178353]

Of course, it is unpleasant that the costs exceed expectations. But what if these drugs are actually more effective? Although, my father had an almost similar situation, although how to look at this situation. Most likely, it will be about how he switched to a stronger drug and eventually earned an addiction. It was difficult, because I knew that these drugs were absolutely vital for him to somehow numb the physical pain that he was experiencing. I am glad that the  Abbeycare group helped us to correct his condition, if you can call it that. He had a hell of a withdrawal. He often broke down and began to use the strongest painkillers again, which contained a large amount of narcotic drugs. But now it's in the past, which I'm very happy about

[somarco]

@RKSK359581 you could have shopped your Part D coverage during the last open enrollment. Pricing for the Express Scripts Saver Plan

Selected drugs Retail cost Cost before deductible Cost after deductible Cost in coverage gap Cost after coverage gap
Invokana 300mg tablet $570.55 $570.55 $35.00 $142.64 $28.53

[RKSK359581]

I did! It was on the formulary!  The change came after open enrollment closed.

[somarco]

@RKSK359581 and you KNOW this because you checked BEFORE 12/7/2020 and have PROOF the drug formulary had changed?

I don't have a wayback machine but I can see that Invokana is not on the UHC formulary today. If you have PROOF the drug was removed AFTER the 12/7 deadline you can appeal.

https://www.uhcmedicaresolutions.com/resources/prescription-drug-appeals.html

The UHC website indicates they notify policy holders 30 days BEFORE removing a drug from the formulary.

UHC owns their PBM (OptumRx) and OptumRx determines which drugs are on the formulary, which are not, as well as the pricing. I will let you draw your own conclusions.

Express Scripts (referenced earlier) lists it as a tier 3 drug.

I don't have a dog in this fight and don't really care if you did your homework or not. But many times folks like the beat the drum of discontent when they fail to recognize, or admit, THEY might be the one who made an error.

[RKSK359581]

 I thought this forum was for AARP members to share information. I am merely a purchaser of that insurance, which I have been satisfied with for 14 years, but an now seeing changes that seem to be  designed to undercut doctors' recommendations and to reduce the availability, affordability and effectiveness of medications. All I can tell you is that my husband was taking Invokana for several years, that it was on the formulary during the open enrollment period, and he had not been notified that it was being removed until after Dec. 7th.  I have no idea when UHC sent out the letter, merely when he received it, nor do I know when they updated the formulary.   The letter gave him a 30 day refill option. His doctor reluctantly switched him to one of the "recommended" options, which has a co-pay of 4 times more than Invokana.   He is just now starting it, so we do not know what side effects there will be yet. 

It was never my intention to make this post solely about my situation, but to use it as an example of what is happening as PBMs are making decisions contrary to medical doctors' prescriptions for the few dollars that they can gain.  My purpose in starting this thread was to highlight this non-medical switching that is undermining doctors' medical choices and get feedback from others who are experiencing the same issues.  It is not just my issue, but that of many across this nation, to expose these issues, and to highlight the studies that show how such non-medical switching affects those who now are not taking their medications as prescribed or at all because of affordability.

Obviously, this is a political issue that affects many, especially the elderly.

[GailL1]

@RKSK359581 

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.

https://www.drugwatch.com/sglt2-inhibitors/invokana/amputation/

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.

https://www.aarpmedicareplans.com/alphadms/ovdms10g/groups/ov/@ov/@highrespdf/documents/highrespdf/4...

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.

(page 78)

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.

[GailL1]

@RKSK359581 

The Way Medicare Part D Works - this Medicare booklet will explain it all.

Medicare.gov - Your Guide to Medicare Prescription Drug Coverage 

Begin on page 26 (bottom) at the heading:

What drugs are covered by Medicare drug plans?

Then continue reading the next several pages (thru page 33) and it will describe the whole process and what you maybe able to do about it, if anything, although at a higher price most likely.  There may also be some new qualifiers added to Invokana.

Now for your dermatology med query - some Injectibles are always given in the Doc's office and therefore are covered under Medicare Part B rather than a prescription drug coverage.

In your case this would also share coverage with your Plan F supplemental.  So dollar-wise, you would come out better, most likely. The real question is why are the insurer is suggesting this site change if they still have the med on their formulary but are refusing to cover it.

Normally, injectible meds given in a Doc's office and covered under Part B are meds that people don't normally give themselves. 

I can only guess but sometimes if you are using a particular injectible in a higher quantity than what the normal quantity might be - say, once a week rather than twice a month - then this suggestion by your drug plan insurer could be so that your doc is aware that his prescribed usage is outside the norm and thus they want him to follow you more closely.  Check with your doc.

Medicare.gov - Prescription Drug Coverage (out-patient) - Part B

[RKSK359581]

Yes, know all of that.  It is still an issue that needs to be addressed throughout the medical system, as these arbitrary decisions based on monetary penny-pinching by the insurers and pharmaceutical companies are harming many by preventing them from getting what their doctors know to be the best treatment based on the individual patient.  Doctors are furious at this as well.  Studies show that such decisions are harming patients who either cannot afford to take the medication prescribed by the insurer rather than the doctor, or who suffer side effects from the medication.  For a description of what I am talking about, see: https://uspainfoundation.org/wp-content/uploads/2016/01/costs-of-non-medical-switching-infographic.p....

[GailL1]

@RKSK359581 

I am not denying that some meds are really expensive but until Congress changes somethings, it is what we have and you have choices.  We all base our healthcare choices on many things, cost being one of them.

It is not the insurers that set the market price of drugs; the pharma companies do - here and worldwide.

There are lots of people that share in the price of a drug between pharma and the end user - manufacturers, insurers, PBM, the pharmacies.  Then you share a part of it too - some people get help from non-profits to pay for certain meds - you share in that cost too. 

Invokana - Savings and Cost support  or Janssen Prescription Assistance 

ALL Insurers negotiate the price of their covered meds via their PBM (Pharmacy Benefits Manager).  These negotiations have a beginning and end date and those do not always correspond to your insurance policy dates (begin/end) so there are gonna be changes during the cycle of your policy. 

Now some people say that we should do like other countries and negotiate the price of medications.  Well that comes with some trade offs too.  For good negotiations to get the best price, the formulary has to be restricted to the best medications for the buck. 

Invokana, as a brand name,  isn't even covered under the VA formulary - it is listed as empagliflozin - same is true of Jardiance - listed as empagliflozin.  The VA negotiates for the meds that go on their formulary - so if a VA doc wants to prescribe Invokana, it will not be covered.  They order it as empagliflozin and then the end user gets Jardiance because the VA looks at all these drugs as being the same.

Follow this along:

VA Formulary search https://www.pbm.va.gov/apps/VANationalFormulary/ 

 Search for Invokana - then just follow it along -

Then Search results:  CANAGLIFLOZIN

Then VA Formulary Search Results for HS502

Search results for Canaglifozin - Criteria for Use - Jardiance comes up

This is what you get.

Are they the same?  Probably not - but close enough - the VA says YES.

And when Invokana goes generic several years down the road (hopefully)

The generic manufacturers will each have a slightly differing formula with fillers

Then if a drug is generic - a person on the VA system will get whichever generic is the choice of the day (the lowest negotiated price).  And this might change from one generic manufacturer to another generic manufacturer periodically depending on who is giving the best price and the best supply of the day.  A person getting their generic meds thru the VA has to keep looking up the medication to make sure that it is the same periodically because the look of the med changes periodically based on which generic manufacturer they are currently using in their supply,

The insurer is only making a cost saving suggestion - it is up to your husband's doctor to make the final call.  Course then you have to make sure that no kickbacks are also involved cause some docs also get a piece of the action on some meds.  Not saying that your doc is one of these heavy prescribers; this is a little old (2016) but you can check it out -

ProPublica Prescriber Check up - Invokana 

It is complicated - right?.