My husband is a type 2 diabetic with mild chronic kidney disease, which has been well controlled on 500 mg metformin BID plus saxagliptin (AstraZeneca’s Onglyza). At the end of last year, he got a letter from his Medicare Advantage PPO, UnitedHealthcare (UHC), advising him that the Onglyza (UHC only uses brand names) would no longer be covered and recommending he have his doctor switch him to another DPP-4 inhibitor, either Januvia (Merck, sitagliptin) or Tradjenta (Lilly and Boehringer Ingelheim, linagliptin). The letter explained that the new drug would only cost $47/month — once his $395 deductible was met. I emailed his endocrinologist, explaining the situation, and he immediately called in a new prescription for Tradjenta. Sounds simple, right? Then, the pharmacy called to say that the Tradjenta would cost $442 the first month, and $47/month after that. But the pharmacist said he could fill my husband’s Onglyza prescription for $100. What do you think my husband chose? Right — the Onglyza. Now, it was complicated enough for him to dump the issue in my lap. He wanted to know why is he being switched to a new, more expensive drug? I said I would call UnitedHealthcare and figure it out. Of course, I didn’t know that meant a 35-minute phone call with two customer service reps. It was incredibly difficult to get to the bottom of this, so I can see why most people just give up. For my husband, if this diabetes medication were the only drug he was taking, one year of Onglyza would cost him out-of-pocket $1,200. One year of Tradjenta would cost $959. So, changing would save him $241 over a year or ~$20/month. What did he decide to do? Stay with the Onglyza since it is effective. “Why fix something that ain’t broke?” was his attitude. And this is not the first go-round we’ve had with diabetes and insurance. Last year, when my husband first started the Onglyza, his doctor and I had the “bright” idea that he should have a month on a continuous glucose monitor (CGM) to see how he was doing in real-time. UnitedHealthcare told me on the phone that CGM was covered. Ha, ha. When I tried to pick it up at the pharmacy, I was told it was not covered. When I complained, UnitedHealthcare said it needed prior authorization, so the doctor got that. But the pharmacy still couldn’t provide it. All told it took me 20 phone calls (actual conversations, not just leaving messages) to UnitedHealthcare (and it took the doctor another 4-5 calls) before UnitedHealthcare finally confirmed it would pay for a covered benefit — but only if we got it from a durable medical equipment company instead of the local pharmacy. My husband was on the new drug so long, and his glucose sticks and HbA1c were doing so well that we decided not to bother with a CGM after all, though I still think it would have educated him about his eating habits. All this said, we’ve been really happy with our Medicare Advantage plan — as long as we don’t have to call them with a question. I decided to write this article because it points out how really hard it is for the typical patient to sort through drug prices, coverage, and copays for a simple drug. I can only imagine what it must be like for patients with complicated diseases. I’m a bit of a bulldog and just don’t give up, but I think many, if not most, patients get too frustrated and just do whatever is easiest, not necessarily what is best. It just has to get easier to get clear information and clear answers from insurers because I don’t think this is just a UnitedHealthcare problem. Lynne Peterson is a writer. Source
