Coverage Flip-Flop

I was talking with some friends at a PBM a few months ago and they were talking about putting Lipitor back on formulary (i.e., the covered drug list) that they took off two years ago.  It made me wonder about what a confusing message that is to consumers.

For years, you are taking Lipitor.  All of a sudden, Lipitor moves to the 3rd tier because Zocor goes generic.  You can stay with the drug and pay a lot more or try a new drug.  Now, 2 years later, Lipitor is back in favor because the manufacturer has offered enough rebates to make the branded drug cheaper than some of the generics.  Great for the manufacturer who extends the life of their drug and reaps economies of scale for a while longer.

But, for consumers, this means another visit or call to the MD.  It may mean more lab tests.  It means changing prescriptions again which could trigger drug-drug interactions or other issues.  It changes physician’s information and sets them up for more calls.

Obviously, changing for clinical reasons is one thing.  Trying to move marketshare and failing is another.  And, simply flip-flopping to save pennies is not logical (to me anyways).  Imagine if your provider was in network one year; out the next; and then back in.  I am sure it happens, but it is a pain.

Hopefully, the savings to the employer, consumer, and benefits to the PBM outweigh any disruption issues.


I guess the question here (as it often is) is alignment of incentives.  I had to wonder the other day when a friend at a large managed care company told me that their PBM wouldn’t implement certain programs for them since they were in the PBMs best interest.  BUT…they save the patients and the MCO (their client) money.  Wouldn’t you at least offer to do them for a fee that covered your lost profit?  (maybe I’m being too practical here)

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