Are Drug Letters Harming Our Patients?

One week's worth of drug letters

Now that a new year has come and gone, I have been swamped with letters from pharmacy benefit manager and insurance companies.  Piles of them.  Not only do these letters consume hours of time each week to address (so much for the "efficiency" of the electronic medical record), I am worried some of the latest practices of these companies might be endangering my patients. 

Here's a typical (paraphrased) letter that has me most concerned:

"Dear Mr or Ms Patient:

This letter is to inform you that Insurance Plan XYZ ("the plan") has provided you with a temporary supply of the following prescription:

(Insert your favorite novel oral anticoagulant name/dose here)

As described in more detail on the following page, this drug is either not included on our covered drug list (formulary) or included on the drug list, but has certain limits on it.

Because you are within the first 90 days of coverage this plan year, TooBig Insurance Company is required to provide you with at least a 31-day supply of this drug.  The supply is less if the prescription is written for less and does not have refills...

It is important you understand this is a temporary supply of this drug.  Before this supply ends, you should talk with your doctor to decide if you should change your prescription.  (Emphasis mine) If your doctor feels that the coverage options listed on the following page are not clinically appropriate for your situation, your doctor can request a formulary exception from TooBig Insurance Company to continue coverage of this drug.

If you need help requesting an exception, please call TooBig Insurance Company Customer Service listed on the back of your member ID card."

Note that all novel oral anticoagulant medications carry a very specific black-box warning from the FDA regarding discontinuation of these medications. Here's the black box warning for rivaroxaban (Xarelto):

"A. PREMATURE DISCONTINUATION OF XARELTO^® INCREASES THE RISK OF THROMBOTIC EVENTS

Premature discontinuation of any oral anticoagulant, including XARELTO^®, increases the risk of thrombotic events. If anticoagulation with XARELTO^® is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant."

Should insurance companies be allowed to restrict the dispensing of any medication where doing so puts patients at risk of injury?  Why are insurance companies allowed to potentially violate FDA-mandated black box warnings if they do so?   How many lives are being placed at risk by this practice?  What about the patients that are blind or can't read?  What happens to them? 

On a more selfish note: why must the physician suffer the liability consequences of an insurer's profit-driven  actions that disregards the safety and well-being of our patients? 

Why?

-Wes