POPULAR DRUGS: Many HMOs Rolling Back Coverage
In an effort to improve their bottom lines, some HMOs have "stopped routinely covering some of the most popular medicines for many members," the AP/Nando Times reports. PacifiCare does not cover either of the top cholesterol reducers, Zocor or Lipitor. Oxford Health Plans charges a premium for Claritin. But leading the charge is Aetna U.S. Healthcare, which recently instituted a three-tiered pricing system that requires members to buy themselves or pay a higher premium for 106 prescription drugs, including Prozac, Lipitor and Prilosec. Generic drugs usually cost members about $5, brand-name drugs on Aetna's preferred list cost $10-15 and those drugs that the company does not prefer cost $25-30 extra. About one-third of all Aetna members are under such a system, one-third have no coverage for the drugs in question and one-third pay the same for all drugs. "It came down to cost," said Nicholas Hanchak, Aetna's drug program manager. Drug costs are expected to rise 20% this year while overall medical costs rise 5%. Aetna said it will spend about $3 billion on drugs this year, a 15% increase from last year, making the restrictions the only means to "keep annual premium increases in single digits."
An 'Educational Effort'
Aetna representatives also call doctors to "convince them to prescribe the lower cost drugs and sends notices to members telling them how much they could save by switching." Although HMOs tout the efficacy of alternative drugs, as well as their own appeals processes, consumer advocates say patients sometimes must fight to get the drugs they need. "I think this is terribly risky and even the HMOs' doctors must know these types of drugs are not interchangeable," said Jim Coleman of the Recovery Initiative, a Cincinnati mental health advocacy group. "It's one of the biggest problems I have in dealing with managed care," said Pittsburgh family practitioner Lee McCormick (Galewitz, 5/23).