Patients shouldn’t have to endure debilitating symptoms day after day when there is a medication that could help them. Yet that’s what’s happening in Mississippi to people with migraine.
Breakthrough medication called CGRP inhibitors actually prevent migraine attacks. By comparison, other medicines just treat their symptoms. For patients who can get CGRPs, the medicine is life changing.
But the state’s largest private insurer has declined to include all CGRPs from its list of approved drugs.
Migraine patients, clinicians and advocates are outraged. After all, the decision limits which medications doctors can prescribe – and which treatments patients can access. Yet it’s not the first time Mississippians with a chronic condition have had their insurer issue a blanket denial for a medication.
People with high cholesterol fought the same access barrier – from the same insurer. For years, innovative PCSK9 inhibitors were off the table because the insurer excluded the cholesterol-lowering drugs from its formulary. In 2018, the price of PCSK9 inhibitors dropped by 60 percent. But the health plan didn’t budge. In fact, coverage for nearly every patient was denied until only recently.
The drugs are now covered. But patients’ access troubles are far from over. Commercial and Medicare plans haven’t adopted PCSK9 inhibitors’ lower list price. This forces patients who pay coinsurance, a percentage of the drug’s price, to pay more out of pocket than they should have to – if they can afford the medicine at all.
Who’s to blame for Mississippi patients’ troubles? The short answer: Pharmacy benefit managers. These middlemen negotiate rebates with pharmaceutical manufacturers and design formularies based on which drugs offer the highest rebates. The practice can incentivize pharmacy benefit managers to exclude certain medications – or to prefer high-price medications even if patients end up with an unmanageable out-of-pocket bill. Pharmacy benefit managers are not required to share those savings with patients. Neither are they required to disclose the details of their rebate transactions.
Some policymakers have had enough. Recent congressional hearings examined pharmacy benefit managers’ dealings and impact on patient access, while proposed reforms would require these middlemen to pass discounts on to consumers.
Until these proposals become reality, however, patients in Mississippi and beyond may lose out, again and again, on drugs that could improve or save their lives.