Insurance isn’t all it’s cracked up to be. We’ve been over this on Twitter. Out-of-pocket expenses remain ludicrously high for many of us, and in my humble opinion insurance gets off the hook way too easily while the media yells at Pharma (which is, of course, its own beast of an issue- but that is an argument for capitalism that goes beyond the intent of this blog post).
It is open season for insurance enrollment, so you would think that the necessary information consumers need in order to select a plan that suits their needs would be front and center. Far from it.
I am under the impression that no one is an “expert” in healthcare anymore. Healthcare is too complex, and varies too much by individual situation, for anyone to truly grasp each nuance at a level of expertise. I am certainly not an expert. But I do have lots of healthcare experience at a young age, having worked in healthcare for many years, lived it as a diabetes advocate, and earned a Master’s degree in healthcare administration while graduating at the top of my program.
Despite all of the above, healthcare remains a Rubik’s cube of complexity, and I have grave concerns with where we are heading from here. How on earth can we expect someone who doesn’t live and breathe healthcare as a total nerd to ever figure this stuff out? We don’t. And that is how insurance banks on us.
Ever since news broke of CVS Health’s ridiculous 2017 formulary removals, which included Sanofi’s Lantus, I have scoured the internet for more information. Would my current insurance provider (which consults with CVS Caremark as a mail order pharmacy supplier) be offering any coverage for my trusted Lantus?
Insulin, too, is its own monster in the healthcare market. While we need more affordable, accessible options for diabetic folks all over the globe, this has created a pharmaceutical conundrum. Pharma companies have answered the call with biosimilar development promised to be more reasonably priced than the name brand options. The Affordable Care Act encourages cost containment, so we cannot be surprised when companies make moves to curtail costs. My main concern with both the ACA and pharmaceutical development, though, is that consumers must still have an element of choice if we expect them to achieve positive outcomes (and, therefore, to control costs in the long-term).
Despite however biosimilars are marketed, we do not know for sure that they are bio-exact. I have worked too hard to relearn the insulin wheel since ditching my defective insulin pump to return to multiple daily injections, and I am not interested in being a biosimilar guinea pig right now. Why mess with the good thing that has been a lower A1c and better quality of life on Lantus?
Bottom line: If I am going to stick with my current insurance plan and provider in 2017, I absolutely need to see in writing if the insulin that keeps me alive each day is covered. A 45-minute call with a Caremark representative this week had us both scratching our heads and simultaneously sleuthing around on the internet and insurance website, desperately trying to find formulary documentation for 2017. Google yielded last year’s list, and searching “formulary” or “Lantus” on the insurer website came up with no matches.
Finally, the Caremark rep found the formulary list buried under a certain tab on the insurance website. My hunch is that insurance companies do not actually want us looking up this information for fear that we may hop over to a competitor offering better coverage of our medications. The good news for me is that Lantus will be covered for me next year, albeit at a higher price. When all is said and done, the biosimilar version (Lilly’s Basaglar) is not that much cheaper…
What a convoluted runaround for not that much gain, which is the moral of the insurance story in recent years.
*If you use FEP Blue, I highly suggest clicking here, here, and, especially, here to learn about 2017 coverage.