Lipitor, for example, is the most commonly prescribed prescription drug to reduce cholesterol and prevent heart disease. It is also a single-source drug with no generic equivalent. While there are other medications (called “statins”) that reduce cholesterol, it is believed that Lipitor’s unique active ingredient makes it especially effective for certain patients, particularly those with acute coronary syndrome or those that have already had a heart attack.
Klein’s report reveals that insurance companies are denying or restricting access to these medications which in many cases disproportionately impact minority communities.
Of the major HMOs operating in New York, 14 place restrictions on medications that are disproportionately required by African-American and Hispanic-American New Yorkers.
Oxford and Independent had the most drugs listed under the expensive third tier, 9 and 4 drugs respectively.
GHI, Aetna, and Excellus listed the largest requirement of step therapy, while Independent required prior authorization most frequently.
Health Net had the highest incidence of quantity restrictions, placing limits on 13 medications, followed by Aetna (10) and Oxford (9).
The senators proposed legislation which would require that all medically necessary prescription medications approved by the FDA be covered by the insurance company. Similarly, coverage of medications requiring step therapy will be guaranteed following the doctor/patient compliance with such requirements.
To address the fact that insurance providers are able to alter their formulary at any time without regard to their patients’ current treatment regimens, the legislation would require that insurance providers will submit their formulary to the NYS Department of Insurance annually. In addition, it would forbid insurance companies from altering the formulary during the year, except in instances where new drugs become available or where single-source drugs lose their patents and generics become available.
Similarly, if a patient is currently taking a single-source drug, and the insurance company alters the formulary so that the coverage of the drug is restricted or denied, the patient will have the right to continue using the drug under the terms that existed before the change.
The State Insurance Department will review and approve an insurance providers’ definition of “medical necessity.” Upon denial of coverage, the insurance provider will submit the reasons for denial according to the NYS Department of Insurance guidelines.