Instability of formulary coverage for drug and insulin can make it tough to treat patients with diabetes, and the problem is getting worse.
Just one example: CVS Caremark removed 22 insulin products and drugs to treat diabetes in its July 2017 formulary update.
“This is a real problem,” Philip Levy , MD, an endocrinologist at Banner University Medical Group in Phoenix, said in an interview. “We have people that are doing well on one medication and then all of a sudden, their insurance carrier says you have to use a different medication and they don’t tolerate it. It’s a real problem.”
Claresa Levetan, MD, with Chestnut Hill Endocrinology, Diabetes & Metabolic Associates of Philadelphia, agreed. “It’s a very big problem. … In my practice, it’s a nightmare because I cannot choose to put them on the insulin or the medications that would be best for them.”
The American Diabetes Association also is concerned. The association is “deeply concerned with recent trends in prescription drug formulary designs that result in frequent changes in drug coverage for individuals with diabetes,” according to a statement.
The situation is made more challenging by the sheer volume of money spent on insulins and diabetes drugs.
Diabetes prescription ranked first among therapeutic classes in terms of total spend (13%), ahead of autoimmune (11.9%) and multiple sclerosis and HIV treatments (both tied at 4.7% each) for its commercial clients, according to pharmacy benefit manager (PBM) Prime Therapeutics. Three of the top 10 drugs by drug spend are diabetes medication (No. 4: Lantus; No. 7: NovoLog; and No. 8: Victoza). For its Medicare Part D clients , diabetes drugs also topped the list in terms of total spend per therapeutic class (14.2%), ahead of oral cancer therapies (11.3%) and respiratory (6.5%). Three of the top 10 drugs by drug spend among Medicare Part D clients are diabetes drugs (No. 4: Lantus; No. 6: Januvia; and No. 10: Humalog KwikPen).
Express Scripts reports similar trends. Diabetes prescriptions were the second highest therapeutic class in terms of per member per year spending in 2016 at $108.80, behind inflammatory conditions ($118.21) and ahead of oncology ($60.70).
Utilization of diabetes drugs increased 5.3%, according to the PBM, while unit costs for these treatments rose 14.1%. Express Scripts identified the top five most costly medications as Lantus, Humalog KwikPen, metformin, Januvia, and Invokana.
“Formulary changes made during the year are particularly troubling because most individuals do not have the option of changing to a different insurance plan that would cover his/her prescription medication,” the ADA said in its statement. “Therefore, the association is strongly opposed to formulary changes such as removing medications from formularies or moving medications to a higher tier during the plan year.”
Beyond cost, Dr. Levetan suggested that another issue is the lack of clinician input at the PBM level.
“I think the problem is not only just companies switching to a cheaper bid mid-year between [manufacturers], but there is really no input from physicians, especially the endocrinologists and the specialists,” she said. “This is potentially life threatening.”
Finding alternatives can also have adverse effects on outcomes and can also be time consuming.
“If somebody is doing well, there is no real reason to change that or to stop it,” Dr. Levy said. “There are some medications that are pretty interchangeable, but others, they all have slightly different side effects and we try to use what we think is the best medication for that patient based on the patient’s characteristics.”
ADA is recommending that PBMs, insurance plans, and employers “provide an expedited and standard process for gaining access to medications not included in the plan’s formulary. Responses to exception requests must be timely to ensure no delay in obtaining a needed medication, thereby preventing a gap in treatment. In addition, the association recommends PBMs, plans, and employers temporarily cover nonformulary drugs as if they are on formulary during the first 30 days after a formulary list is changed.”