CVS Prescription Plan Drops Big Name MS Drugs from 2017 Formulary
The CVS Caremark covered insurance plan has dropped Avonex, Plegridy and Extavia, three multiple sclerosis disease-modifying therapies, from their 2017 formulary.
You say, OK, but what does that really mean? If your prescription insurance is through CVS Caremark, and you want one of those drugs or one of the other 130 that were announced as off their formulary for next year, you can still get it, but you have to pay the full price. Your CVS Caremark insurance will no longer cover those costs unless your doctor is able to successfully appeal the formulary decisions.
Why would CVS do this? The bottom line is company profits for the stakeholders. CVS Health’s statement to their stockholders and clients reads:
“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 2,856.8 percent in the last three years.”
“Our rigorous approach to formulary management will help generate a total savings of more than $9 billion for clients from 2012 through 2017.”
There is no argument from me that the price of drugs in this country, especially the costs of MS DMTs, can be astronomical, but it concerns me that decisions on treatments are being made based on costs and not doctor recommendations. I want me and my neurologist to decide what might be my best treatment and not my insurance company.
This is nothing new for expensive drugs to be removed from the formulary (those lists of approved and covered drugs). It was only a few years ago that Rebif was booted from one list, but they regained approval the following year. Excluding drugs from the formulary is a way that drug insurance providers will use to force a better discount from the drug manufacturer. It is also used to force consumers to accept generic over brand-name drugs.
It might be worth your time to look over the list if you are one of the 85 million customers of CVS Caremark insurance to see if any of your other drugs are also off the list. You can read the entire group of 130 drugs and see it includes those in many disease areas, including HIV and cardiac care.
If you happen to be among the unfortunate people who take one of these drugs and are a customer of CVS Caremark, you should be talking with your doctor now about options. Sometimes the drug plan coverage will grant exceptions, but it takes a lot of paperwork and time to complete and that needs to begin now and not in January 2017.
Note: Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Multiple Sclerosis News Today, or its parent company, Bionews Services, and are intended to spark discussion about issues pertaining to multiple sclerosis.
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Cindy Winters
Yea! The rising costs of pharmaceuticals have to be contained. By whom is the question. I applaud CVS for taking this giant leap and hope others follow. They are replacing those that have suitable substitutes. As a conscientious consumer I shudder each time I order my outrageously expensive Ampyra knowing 4AP is out there for a mere fraction of the cost.
Laura Kolaczkowski
The problem I have with this is the pharmacies are forcing patients to make the change rather than dealing with escalating drug costs at the corporate and stockholder level. I too shudder at my drug costs, but also know that what I take appears to be working for me and I hope I am never forced off of it. Treating MS is such an individualized process and what might appear to be a reasonable substitute may not be at all for any given person. -Laura
Melissa Vemi
If my parents didn't help me to get a Medicare Supplement Plan I wouldn't be on tysabri now because the 20% I would have to pay would be astronomical to me and my meager Social Security disability income.
Laura Kolaczkowski
Melissa, there are so many people in the same way that they get by financially with the help of their family. Biogen's patient assistance workers are masterful at helping people such as you find sources of money to help with these costs. Please call them and ask for their help - and let me know if you encounter roadblocks and I might find other suggestions for you.
Jan
I have had Dx MS and have taken no DMD. Now Neuros say that I'm SPMS because of that ("and no drugs for YOU." Maybe Ampyra, but insurance pulled the plug. Then they said 4-AP. I was ready to try, but they pulled the plug on their own demand. I recently submitted the 4AP to my current neuro, who said no. I'm furious with both doctors and big Ph.
Shelly
I have MS, I tried the generic Copaxone and all of my symptoms flared up. I went back to the original and my symptoms subsided. If I want the original will I have to pay $2500 a month now? I may as well shoot myself because I'll be disabled very quickly after I can't afford my meds.
Laura Kolaczkowski
I have heard some not so good reports about the generic, including your comments here. I hope you are proactive and verify your coverage before January 2017 arrives. - Laura
Phil Sypula
Thank You , For leaving the list, Phil Sypula ... I'm in my 17 th, year after being diagnosed with MS ... YEA !!! AND NO, IT IS NO FUN but we all live with it ...
Laura Kolaczkowski
sharing information among us is essential - we really are all in this together. I'm glad we could get this news out now to everyone so you can look at options. -Laura
Michelle
I agree prescription medications are horribly expensive; however, why should the patient suffer more because the pharmacy wants to save money? I take Gilenya, which is about $6000 a month. There is no way I could afford that out of pocket, even if I were not disabled and unable to work. This drug has stopped the progression of my MS. I am praying it is not one of the meds being removed from the formulary.
Philip Posner
Thanks for the heads up. I now have 5+ months to figure out how to pay $5-$6K per month for the Avonex that has kept me functional since 1999. I have been told by CVS, that if I successfully appeal, CVS would provide the Avonex at full market price rather than a tiered co-pay.
Without your post, I might have been notified of the increase until January when I tried to renew my prescription.
Laura Kolaczkowski
This is the power of Social Media personified in health care.... thanks for sharing your situation, Phil. I'm glad to save you distress in January and instead give you time to plan and wring your hands now. - Laura
GARY SHAMBLEN
Great comments! However, in my opinion, until an organized effort by those whose health is directly affected by profit driven decision making, things will get worse for patients.
GARY SHAMBLEN
When a prescription is denied or going to be, we have right to file appeals. I was successful in receiving coverage of a prescription following three(3) denials. In order to receive coverage for a non-covered prescription you must show Medical Necessity. Following the Formal appeals and denial you have the right of a Peer to Peer Conference that can be scheduled via telephone. That requires the cooperation of a Neurologist discussing the patient's individual need for the medication with an insurance representative of same specialization. It's a good idea to remind your Dr. to make sure of that. You may need to work with your physician in documenting reasons for the Medical Necessity. If again denied, then it can be brought to civil court
Laura Kolaczkowski
That process sounds exhausting .... and one that people might need to begin now so there is no significant lapse in treatment time. Thanks for sharing this.
GARY SHAMBLEN
Yes plan early and it can be exhausting, if we let it. I try to look at these situations as the hours I spend vs the dollars saved. A nice surprise is calculating the hourly rate earned not only for now but down the road..
Casandra
Diagnosed less than two years ago I am blessed to pay nothing for Tecfidera with the financial assistance program from Biogen in addition to my private insurance coverage from University of Dayton. I still am able to work full time. Walking distances is my challenge. I miss my 9 mile Saturday walks and my 3 to 4 mile lunch walks three days a week at work. I now have a BalanceWear vest also at no cost. My spring goal is to increase walking distance. I have custom orthodics arriving before Xmas and just started taking Lyrica for the pain in my feet, left hand and left scapula.
P.S. I started on Tefidera for several months then tried Abaugio for several months as my neuro thought that would help the pain. It made it so much worse that I ended up with plantar fasciitis. I am thrilled to be back on Tecfidera.
happy Holidays to all!
Kimberly Smith
I was diagnosed in November of 2017 after three MRIs and numerous other tests. My husband initially mentioned that he thought I may have had a minor stroke because my coordination was suddenly off and after the first MRI,I was diagnosed with Demyelinating disease which is how I met my neurologist. I am on Betaseron injections and right now my husband's insurance is refusing to pay again,even though they had the letter from my doctor approved through November of this year. They now want a second letter so I am without my medicine since this has been going on for almost two months. I can honestly say, I feel worse after starting treatment than before I even knew I had MS. By the way, my husband has CVS Caremark for our insurance.