Bill Would Limit Patient Access to Cheaper Drugs

More than 25 million Americans suffer from asthma. The condition is well-known for restricting a patient’s airway, making it difficult to breathe and often causing coughing and wheezing. In addition to putting the squeeze on a person’s lungs, asthma is also putting pressure on patients’ wallets, as the cost of inhalers has risen to about $5,000 a year.

Doctors and patients were recently elated when a popular asthma medication went generic. Fluticasone/salmeterol is the first-ever generic asthma combination inhaler. It contains the same active ingredients as Advair, but for a fraction of the price – $119 per inhaler compared to $360 per inhaler. Hearing the news, CDPHP immediately moved to add the drug to its formulary (list of covered drugs), saving an average of $3,500 per year.

But what if we weren’t allowed to offer the generic to our members?

A bill circulating in the New York state legislature would do just that by prohibiting health plans – like CDPHP – from making formulary changes in the middle of a contract year. The legislation (S.5022-C/A.2317-C) purports to protect consumers from being forced to change medications mid-stream, but would lead to several unintended consequences that are bad for consumers.

Health plans are constantly searching for ways to provide consumers with access to the most clinically- and cost-effective drugs. One of the ways we do this is by updating our formularies. CDPHP and other health plans make decisions about prescription drug coverage alongside local, practicing doctors – doctors who are not employed by the plan, but sit on our pharmacy and therapeutics (P&T) committee. When a new drug comes to market, the P&T committee meets to determine whether the drug should be added to the list. Prohibiting plans from making these changes would not only limit consumer choice, but would increase the cost of care for all.

Doctors and advocates – many of them propped up by the pharmaceutical industry – will argue that mid-year formulary changes are bad for consumers. What they’re failing to mention is the impact that mid-year price hikes have on patients.

We all remember the outrage when then-Turing CEO Martin Shkreli increased the price of Daraprim from $13.50 to $750 overnight. Then there was Lomustine, a cancer drug sold by Bristol-Myers Squib that used to go for $50 a pill. The drugmaker sold the rights to a startup called NextSource, which jacked up the cost nine times. One capsule of the life-saving treatment is now $768.

At CDPHP, we believe members should have access to safe, effective, and affordable medications. Limiting our ability to be agile and respond to market changes is not in the best interest of consumers, and potentially another big win for Big Pharma.