In the last month I have learned something I didn’t know before, and I am not at all happy about it. “Too soon old, too late smart,” as Mom used to say.
The insurance company that covers your prescriptions can, at any time during the year, remove those drugs from its formulary whereas you, the insured, are locked into your contract with that company for the year.
It’s all explained in a 2017 Pro Publica article that I found: “Take the Generic Drug, Patients Are Told — Unless Insurers Say No.” (It was published simultaneously in the New York Times.) Interestingly, the company cited in the article’s opening is Humana, the company I’m with (for now, anyway).
I found the article while searching for an answer to my silent, angry “Can they do this!?” “This” would be my Medicare prescription plan abruptly refusing to cover my generic eye drops for glaucoma. Now they say they will only cover the brand name drug. So instead of $50, I’ll be paying $220 or thereabouts, depending on the pharmacy. I’ll be on the hook for at least $1700 more this year than I expected.
The article says most or all insurance companies can and do operate like this, changing their formularies at will anytime during the year, while we insureds can only change companies when our annual contracts end. A few states have laws forbidding such mid-year changes, but not mine.)
No, it doesn’t make sense for an insurance company to stop covering a cheaper option and limit you to the more expensive brand name drug. But they can and do. The pharmaceutical companies pressure them to do it in order to protect their lucrative brand name drugs from the competition of cheaper generic versions. Not until I read that article did I understand what was going on.
My initial reaction was damn it, I’ll change insurance companies at the end of the year! But there’s no guarantee a new company that currently covers my generic drug will continue to do so. It, too, might drop the coverage at any time.
I’ve been a reasonably happy Humana enrollee for about five years. I’m not sure I want to try for six, but the alternatives don’t sound much better.
(Meanwhile, there’s the insurance companies’ move-generics-to-a-higher-tier ploy, but that’s a whole ‘nother story.)
(P.S. In April 2024 I wrote about a closely related situation, the pre-authorization gimmick that hit me then and also triggered this incident. Like so many other things, I’d forgotten it.)
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My wife changed insurance this year because we didn’t like what the last was doing (or not doing). Somethings are better, some worse. It’s so hard to say if the switch was worth it.
Yep, that’s what I’m afraid of. Until now, I’ve had no complaints with Humana. But I’m really ticked about this formulary thing, not only because it’s going to cost me more money but because it’s just WRONG that they can change the terms of an agreement in the middle of the year when patients can’t.
My military-provided pharmacy, Express Scripts, always provides generics, so far as I’ve noticed. The practice you describe is shocking, but maybe it shouldn’t be. Big Pharma is the most profitable industry in the USA, or at least it was at one time, probably still is. There is a reason that drug ads on TV are ubiquitous. The excuse they use is that it costs a lot of money to develop the drugs but the truth is, drugs are mainly developed by scientists at places like the NIH. Big Pharma does incur the expense of testing new drugs for approval.
Suffice it to say, I am angry about this. It’s not right that those formularies can be changed anytime the insurance companies feel like it, and we the powerless are locked in for the year. I have several relatives who, probably like millions of others, choose their insurance company according to which one will pay for their particular very expensive medication(s).
I just fired off a letter to my two representatives in the Colorado General Assembly, and CC’d a local investigative reporter, but I don’t expect anything to come of it other than slightly lowering my blood pressure. (I can’t believe Texas and New Mexico have laws against this practice and Colorado doesn’t.)
That’s news to me, too. Maybe we should support Kennedy’s efforts to break up big pharma.
I support his efforts to stop their advertising, but that’s where my support ends. However, as I noted in my previous comment, I did fire off a letter to my reps in the General Assembly. If other states can forbid this practice, so can Colorado!
The issue of pharmaceuticals in your country has forever been one of the most appalling examples of the power of Big Pharma; no wonder Obama was so chuffed when they managed to squeeze through what they did. I fear I must say that this fits in with the US’ utilization of lobbyists – all part of Business running the country. Big Pharma might be called a subset of Big Business, I suppose …
Mind you, the corporations run Oz, and that’s a fact. 🙁
Oh yes, Big Pharma is indeed Big Business. But they wouldn’t be quite so bad if Congress hadn’t voted them permission to advertise prescription drugs directly to consumers. All that advertising money could and should have been going into their R&D. Lobbyists don’t strike me as any worse than salesmen or PR guys; the evil is legislators acceding to lobbyists’ wishes (and bribes).