June 01, 2018
I think one of the hardest parts of working in managed care is balancing the need to provide value on a population scale while not forgetting the individual patient perspective and information gap. Policies, criteria, and coverage decisions that make sense for a population do not always make sense for an individual patient. There are of course processes in place to allow for individual exceptions when medical necessity exists, but what do we do for those who feel that they have a need that is not easily demonstrable under medical necessity rationale to understand the decision?
A neighbor of mine was recently talking to me about his medications. Knowing that I am a pharmacist working in "pharmacy insurance" he wanted to know if I thought a new medication was going to be covered by his health plan. He has been taking Lyrica (pregabalin; Pfizer) for years to successfully treat his pain stemming from a neurological condition. As we were talking, he told me that he has at times found the need to take Lyrica multiple times per day burdensome because he has to make sure he plans his day so he will have his doses with him. If he forgets to do this, then he experiences a worsening of his pain symptoms. My neighbor's physician had recently mentioned to him the approval of Lyrica CR and the once per day dosing it is going to offer. My neighbor saw a ray of hope in being able to get his needed medication in a more convenient schedule. He asked me if his plan would cover Lyrica CR as they have already been covering his immediate release Lyrica.
I was able to explain to my neighbor some of the factors his plan was likely to consider when determining coverage of Lyrica CR including wholesale cost, potential rebates, the anticipated availability of a generic for immediate release Lyrica in the next 6 to 12 months, and the richness of drug mix his plan chooses to offer. By being able to discuss these factors one by one, my neighbor was able to come to his own conclusion that it might not make sense for his plan to cover the CR version as his plan focuses heavily on driving generic medication use. He was understandably disappointed that coverage of Lyrica CR was not certain but was glad to understand the reasoning behind this potential decision.
In situations such as my neighbors, his desire for a more convenient dosing schedule is likely not going to be considered reason enough to grant a medical exception for coverage. The potential coverage policy that makes sense on a population level in order to decrease plan spend may not make sense for the individual patient's experience. My neighbor is lucky enough to have my knowledge of the industry to help him understand what goes into a decision for drug coverage, but the vast majority of patients do not have access to a managed care professional to get this information.
While there is not a quick fix to this information gap, I think those of us who work in managed care can keep this in mind and do what we can whenever we can to help individuals understand their drug coverage. Some ways I have seen this happen include providing clear explanations for any potential denials for prior authorization or medical exception requests, ensuring the member facing call centers have pertinent information to provide members when they call in about a needed drug, and providing clear point of sale messaging within claims adjudication so a member's pharmacy can tell them exactly why a claim is being denied. As managed care professionals, we will never be able to make every member happy with every decision we make as we manage our populations, but I do believe we need to keep individuals in mind and provide every piece of information we can at every opportunity available.
—Russ J Spjut, PharmD
Russ J Spjut, PharmD, is owner of Formulary Intel Consulting. He is a residency trained pharmacist in managed care with experience in both commercial and Medicare Part D PBM operations. He has been involved in formulary management, P&T committee presentations, clinical program development, formulary strategy, clinical analysis, client management, and review of coverage determination requests for a major health care management company.
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