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When critical medications leave the formulary, patients can be devastated

At the beginning of this new year, a worrisome change took effect for patients with chronic illnesses across Minnesota. Many patients have just become aware that their current medical treatment will no longer be covered, which may have a serious impact on their health in 2017 and lead to consequences beyond.

Dr. Jody K. Hargrove

Medica, the second largest insurer in the state, along with its pharmacy benefits manager, CVS Caremark, has made the unprecedented decision to eliminate a number of critical medications from the medication formulary for 2017. This means that patients with diseases including rheumatoid arthritis, psoriatic arthritis, psoriasis, multiple sclerosis, and hepatitis C may no longer have access to life-changing medications, which have stabilized their conditions.

The insurance company will explain that they are not preventing you from using these drugs; however, the patient will then have the untenable task of paying full price out of pocket. Physicians can spend a significant amount of time writing individual letters of appeal for patients only to have the request denied by someone with significantly less training and experience and who, more essentially, knows nothing about the patient.

As a rheumatologist with 27 years of experience in private practice, I treat life-long and incurable diseases with few medication choices. Autoimmune diseases most commonly occur between the ages of 20 and 50, affecting people starting their families and establishing their careers. These diseases are more common in women. Medications can modulate disease but often become ineffective after time periods averaging three to five years. Removing several drugs from consideration clearly limits options for a patient. Changing medications like this can be devastating for anyone with a chronic disease.

I feel sad for patients with autoimmune diseases, diseases that they did not cause or ask for and cannot control. They are being targeted by rationing of care with financial interests solely as the basis. My colleagues and I want the public to understand what is happening in the real world and that we will continue to advocate for what we feel is best for our patients even though the insurance companies really are making the medical decisions. Limiting medications for our patients could easily lead to expensive emergency room visits and hospital stays. It will certainly lead to increased numbers of people with disabilities, an expense for all of us as a society. Especially notable in the case of rheumatoid arthritis, where early intervention and disease control has been proven to lower later (and expensive) costs such as joint replacement surgeries as well as other hospitalizations. 

My colleagues and I asked Medica to delay implementation of its policy because physicians were first officially notified about this on Dec. 20. Additionally, we asked that it might “grandfather” coverage of medications for the patients who demonstrated good disease control on a medication that was no longer covered. It declined.

If you are a CEO, a COO, a human resource specialist, a benefit specialist, a legislator, or just a concerned person, please help us speak out. Rheumatoid arthritis, psoriasis, psoriatic arthritis, and similar disease all affect someone you know. It could even be you. Make your opinion known: Send an email to your legislators at both state and national levels, call out your neighbor who works at Medica, consider another insurance plan if you have the option. We must let physicians — not insurance companies — practice medicine.

Jody K. Hargrove, M.D., is the president of the Rheumatology Association of Minnesota and the Dakotas and a practicing rheumatologist in Edina.

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Comments (2)

Thank you

Thank you for writing this. I know this to be all too true.

Can there be any doubt that

Can there be any doubt that health insurance companies are evil immoral entities?
How does someone work for a company like medica and sleep at night?
This country is a joke and it only seems to get worse and worse.