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New Insurance – Bad Medicine

Posted by March 8, 2011 at 1:01 PM

A new patient recently came to my office.  He got a new job, moved to the area and came to see me to establish care and get his prescriptions filled.  He has a few chronic diseases but controls them well with lifestyle and meds.  Among the prescriptions I renewed that day was atorvastatin at 40mg per day.

Several days later I received a letter from his new insurance company.  They refused his atorvastatin as it is a non-formulary drug.  I looked through his old records and discovered that in 1998 he was diagnosed with elevated lipids and started on pravastatin.  His dose was maximally increased but lipid goals were never achieved.  At that point he was changed to the more expensive atorvastatin and he has had satisfactory lipid levels since.

I explained this to the insurance company in a letter.  They replied by saying that if he could not be managed on a generically available statin that other formulary options were rosuvastatin or simvastatin/ezetimibe.

Well this really got me fired up.  I understand formularies and the desire to use effective and less expensive medicines whenever possible.  But here we have a patient who has been very well controlled for 13 years on medicine and he is being asked to change now.  And not just to a new medicine but to a medicine that has less or NO evidence that it positively impacts mortality or serious coronary events.

It is deplorable that because my patient had the good fortune of getting a new job that he is expected to change from an effective, well-tolerated medicine on which he has been stable for 13 years to another expensive medicine that has little or no supporting data.  This is another illustration of how our private insurance companies are more interested in the bottom line than in what is best for our patients.

One Response to “New Insurance – Bad Medicine”

  1. Cheryl Bettigole, MD, MPH says:

    Agreed — I’ve had this same discussion with insurance companies about statins. I’ve also spent way too much time this month dealing with an HMO that does not cover Coumadin without prior authorization. They actually sent me (and my elderly patient) a letter saying that she would have to fail warfarin before they would authorize coumadin. This left both me and my patient wondering if anyone reads these letters before the insurance companies mail them. Did they mean that she’d need to have a stroke first or just a DVT? This is where regulation of insurance companies starts to look pretty darn attractive. Thanks for your post.

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