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The debate over drug formularies

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Kelly Mandryk:

I think a big challenge with managed formularies is that they haven’t found a way to address the different uses of the same drug.

For example, they evaluate birth control pills based on their ability to prevent pregnancy and choose the most cost effective drug. However, doctors prescribe birth control for many different types of conditions such as heavy periods, control of endometriosis symptoms, severe PMS, etc. and the drug that is the best to prevent pregnancy may not be the best to treat these conditions, or may it be the safest based on the patient’s risk factors for stroke and heart attack.

I would argue that endometriosis is a more severe condition than the need to prevent pregnancy, yet the member with endometriosis is the one who will be financially penalized by a managed formulary.

I also strongly disagree with the assertion the insurance companies have no dog in the fight. Yes, it’s true that insurers charge fees based on claims paid through ASO plans, but a group will go to market if they feel their costs are too high. Insurers play an important role in helping clients manage their drug costs, and if they don’t do it well, they pay by losing the group to another carrier.

Wednesday, July 12 at 11:30 am | Reply

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