| Blue Cross Limits Access To Meds | |
Now a Patient Advocate Enters the Situation
Enter: The Patient Advocate:
At Miss Brown's request, I prepared to contact Chris Luke, the person to whom
she had spoken at Blue Cross Blue Shield of Florida. The first thing I did was
place a phone call to the
FDA in order to get on record what I already knew — there are no FDA
regulations regarding insurance coverage of medications. I spoke with Ms. Brenda Stodart at the FDA who confirmed that the FDA has no jurisdiction over any
insurance company. The FDA regulates the pharmaceutical industry, not the
insurance industry, and no FDA regulations would have any effect on payment for
prescription medications.
Next, I contacted Mr. Luke, identifying myself as a patient advocate calling on Miss Brown's behalf. After pulling her records, he told me that they couldn't cover more than 120 mg per 29-day period "because of FDA regulations." When given the information I'd received directly from the FDA, Mr. Luke asked me for the name and phone number of the person to whom I'd spoken and asked to put me on hold. He returned approximately 15 minutes later with a different reason not to cover the Maxalt. He said that their medical review staff had "been told by experts that triptans are addictive." Offering to provide him with names of excellent Migraine experts, I explained to him that triptans are not addictive, and that the FDA-approved prescribing information states they're not addictive. Mr. Luke told me he'd have to consult their medical review staff and get back to me.
During our next conversation, Mr. Luke quoted me a section of a contract that he'd never mentioned before. It refers to Maxalt, and he stated that this is a part of Miss Brown's policy:
"This medication is covered by your plan's base day and quantity limits. The dispensing limits apply through the managed Rx coverage program. Reason: Federal Legend drug dispensing limits apply through the managed Rx coverage program. Maxlat®, Maxalt-MLT® to be dispensed at a max of 120 mg in 29 days or 360 mg in 67 days."
When I reported this information to Miss Brown, she told me unequivocally that the paragraph is nowhere in her policy or in any printed material she has ever received from Blue Cross Blue Shield of Florida. In examining a copy of her policy and related materials, I could found nothing resembling the paragraph above either.
Since MAGNUM, the National Migraine Association has been working on and deeply concerned about triptan limitation issues for several years now, I also contacted MAGNUM staff members for their observations and input regarding this case.
MAGNUM Founder and Executive Director Michael John Coleman commented:
"Limiting access to Maxalt® or any other triptan or other medication is inappropriate. In this case, I find it interesting that the third explanation refers to to a clause in the policy which evidently in Ms. Brown's policy does not exist. However, let's say it did and this their clause is their answer to you regarding this case. Then we've gone a complete 360 degrees back to the beginning with them referring to Federal Legend dispensing limits. "Federal Legend" is, in fact, the FDA-approved prescribing information label or sheet. Therefore, they're intonating that there is a federal regulation or code when one does not exist. MAGNUM finds this deeply troubling. What concerns MAGNUM is that this appears to be a managed care provider trying to manipulate federal codes and regulations in the name of patient safety when, in reality, it's a veiled attempt to cut costs."
Ms. Terri Miller Burchfield, Legislative Director for MAGNUM noted that the very Federal Legend that Blue Cross Blue Shield refers to in that clause clearly points out that Maxalt is not addictive.
Mr. Coleman is going to forward this investigative article to an appropriate Congressman to make him aware of this possible abuse. It's MAGNUM's hope that managed care providers, when made aware of this inappropriate use of federal regulations in limiting access to medications properly prescribed by the patient's attending physician, will cease and desist. As MAGNUM points out, a managed care provider should be watching out for the patient, but points out that where a bureaucrat is looking to save $19.13 for a pill, they may ironically end up costing them $1,900.00 on an emergency room visit, not an efficient way for the managed care provider to spend their money.
I concur with MAGNUM's analysis of my communications with Blue Cross Blue Shield. When presented with direct information from the FDA that their first reason for limiting triptans, supposed FDA regulations, was incorrect, they next presented me with potential addiction as a reason for limitations. Once that was shown to be incorrect, they came back with a non-existent policy clause that circles back to the FDA. As mentioned earlier, the FDA has absolutely no jurisdiction over the insurance industry. It seems that Blue Cross Blue Shield either has no sound reason for their limitations or is, for some reason, reluctant to disclose that reason to me. It appears that managed care providers in general take a position when they deny access or attempt to change an attending physician's orders, which MAGNUM and others think is akin to practicing medicine without a license. Or, the managed care provider has a medical doctor on staff who is reviewing the case and unilaterally changing the attending physician's orders without ever examining the patient, an action which could possible be construed by some as medical malpractice.
In the interest of balanced and fair reporting, I consulted Blue Cross Blue Shield repeatedly during the writing of this article and invited their comments and/or statement prior to the stated publication deadline. At the time of this publication, they had made none. I'm looking forward to their comments and will include them in next week's follow-up article.
Please check back next week when we'll report on the outcome of this important case.
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