What would you do if your new insurance plan wouldn't cover the medication you depend on?
One drug, two costs
David Garden - a Santa Monica slow growth advocate and self-professed rabble-rouser - has a form of muscular dystrophy. For the past two years, he's taken Cymbalta, which is commonly prescribed for depression, but also alleviates the chronic neuropathic pain associated with his disease.
Garden, who worked as a camera technician, had employer-sponsored Anthem Blue Cross insurance through the Motion Picture Industry Pension and Health Plans. When he retired at age 45, in part due to his condition, he continued this coverage through COBRA for 18 months.
Throughout that time, a 90-day supply of the medication cost him a cool $25 co-pay.
When his COBRA ran out, Garden decided to buy insurance on the Covered California exchange. He stuck with Anthem Blue Cross. He'd already bought the plan when he learned that neither Cymbalta, nor its generic version, were covered on the drug formulary for Anthem’s Covered California plans.
It suddenly cost Garden $512.77 to fill a 90-day supply of the generic version.
What's up with that?
I reached out to Darrel Ng, PR director for Anthem Blue Cross, and asked if it was possible that Cymbalta, or its generic version, would be covered under one Anthem plan but not another.
According to Medscape, Cymbalta is one of the most prescribed drugs in the country.
Ng responded via e-mail:
"Covered drugs and other benefits vary by policy. Large employers have a lot of latitude to decide what type of coverage they'll offer the employees."
"The drug formulary on the exchange was based off of the drugs covered by the Kaiser small group plan. So it's very likely that there are drugs that are on an Anthem large group plan that aren't on the Anthem exchange plan."
When I pressed him further regarding Cymbalta specifically, he said:
"…Anthem’s formulary was filed with and approved by state regulators."
"I'd also note that there’s an exception process for drugs that aren't on the formulary. To initiate that process, members should contact customer service."
So, this is really a thing?
I asked Marta Green, the spokeswoman for the state Department of Managed Health Care, the same question: Is it possible that a drug as common as Cymbalta is covered under one version of a plan, but not another?
In her response, she explained the federal rules about drug formularies:
"Individual and small group (non-grandfathered) health plan formularies must meet certain standards in federal and state law – but these rules do not require any one specific drug to be included, rather they require that plans include a certain number of drugs by category and class."
"In addition, all plans must have procedures in place that allow an enrollee access to medically necessary drugs not covered on the plan’s formulary if their condition warrants the use of such drugs."
"If a health plan denies access to a non-formulary drug on the basis that it is not medically necessary, the enrollee has the right to an independent medical review."
Garden has already tried to navigate Anthem's exception process, but he has hit roadblocks along the way: The first time his doctor requested coverage of Cymbalta, it was denied. A clinical reviewer determined the drug wasn't a "medical necessity" for his disease - which was miscoded as multiple sclerosis.
The second time, his disease was corrected - but the reviewer again determined that the drug wasn't medically necessary. She said the FDA hasn't approved the use of Cymbalta for his condition - a point that he's contesting.
Garden has written a letter to Anthem's Department of Grievances and Appeals, asking it to reconsider its decision to not cover his Cymbalta. He wrote:
"I believe the Anthem Blue Cross clinical reviewer... did not properly investigate the use of Cymbalta for chronic pain. It is one of the only non-narcotics that are approved by the FDA for the condition of chronic musculoskeletal pain."
We'll see if that persuades Anthem to conduct an independent medical review of Garden's case.
Garden has also written to the Department of Managed Health Care to complain that it's very difficult to determine which drugs are covered under an insurance plan - a problem I've reported on before.
In the meantime, what’s a rabble-rouser to do?
For the past month and a half, Garden has been getting sample pills from his doctor, and carefully cutting them in half.
If the situation isn't resolved soon, he says he'll try to fill his prescription through a supplier in Canada.
Are you struggling to afford the medications you rely on? Tell us about it in the comments section below, or e-mail us at Impatient@scpr.org. Your experience could inform future reporting.