Here we go again…. The fight to get access to the multiple sclerosis disease modifying therapy (DMT) that works for us becomes a real struggle when our insurance company decides to ‘drop’ our DMT from their formulary. Insurance drug formularies are the list of drugs that are ones that will be covered. Anything not on the formulary is not routinely allowed to be used by the person who is insured by that company, although some doctors have been successful in fighting and getting these drugs covered in other ways. If you want to use a drug that is not on the formulary, you will be expected to pay 100% of the cost.
Excluding drugs from the formulary is their way of trying to control the cost of drugs, and each year the list includes some surprises. In a story on NPR, it was discussed that ExpressScripts and CVS Caremark, two of this country’s largest prescription drug providers, have removed a large number of drugs from their formulary, including a few of the MS DMTs.
The ExpressScripts list has 85 drugs they will no longer cover, and fortunately it appears none of them are the DMTs. The story for CVS Caremark’s list is different and their excluded drugs for 2017 include the DMTS Avonex, Extavia and Plegridy. CVS Health told investors in a document that this move is in reaction to inflated drug costs and their attempt to contain those costs.
“CVS Health is taking a stand against egregious drug price increases that unnecessarily add costs for clients and their members. On a quarterly basis, products with egregious cost inflation that have readily-available, clinically-appropriate and more cost-effective alternatives may be evaluated and potentially removed from the formulary. For example, among the hyperinflationary drugs that will be removed in 2017 is Alcortin® A External Gel by Novum Pharmaceuticals which saw a price inflation of 2856.8 percent in the last three years.1
They also make the claim to their stockholder/investors-
“Our rigorous approach to formulary management will help generate a total savings of more than $9 billion for clients from 2012 through 2017.2
None of us can dispute that MS drug costs are out of control, with increases in pricing occurring regularly. But, I would also argue that by limiting our access to these drugs, CVS Caremark and other pharmacy providers, are doing a job that should be done by our doctors. Our physicians know best what drug we should have access to and this should not be left to large corporations that are concerned about their bottom-line profit.
If you are currently using one of these excluded drugs and are covered by these pharmacy providers, you want to be proactive and begin now in talking to your doctors and making plans to appeal the use of your DMT and/or deciding on what DMT switch you might make. It’s critical that you don’t wait until January 2017.
Wishing you well,