While there is still no cure for migraine, there are more options than ever for relieving and preventing the painful and disabling neurologic condition.
This increase in options is being undermined, however, by rapidly expanding exclusion lists. Each health plan has one: a list of drugs and devices it won’t cover, even if physicians prescribe them for patients. The lists are determined by pharmacy benefit managers who work for health plans.
Lists Keep Growing Longer
Patient advocates and medical societies have protested these profit maximizing lists as barriers to patient-centered care. Even still, they keep growing longer with stunning speed.
In 2022, the three largest pharmacy benefit managers had a total of 1,156 unique medications on their exclusion lists. This is a 29% increase over the previous year.
The Need for Treatment Options
Exclusion lists are another form of non-medical switching that is undermining treatment in all areas of medicine, but the impact is especially damaging for those living with migraine and other headache disorders. Providing these patients with relief from painful attacks requires availability of a variety of treatments as the most efficient option can vary from person to person.
The lists create a barrier for patients who have not yet tried an excluded medication, placing potentially life-changing therapies entirely out of reach. As for patients who are successfully using a medication that gets placed on an exclusion list, they will have to pay the full cost of the drug to continue using it. The delays and denials of prescribed treatments via exclusion lists cost in other ways, too:
- Time Cost. Time wasted forcing patients to try other treatments can allow their disease to become more chronic, causing a ripple of other consequences.
- Health Costs. Switching treatments can lead to reemerging or new symptoms and greater pain.
- System Costs. Migraine disease inadequately treated can lead patients to seek urgent or emergency care and schedule additional medical appointments.
Appeals processes are time-consuming and don’t guarantee success. And should patients be expected to switch or appeal annually as payers bump and rotate approved drugs from year to year?
Exclusion lists were originally created to promote the use of less costly but equally effective generic substitute drugs. But in recent years, pharmacy benefit managers have evolved to using exclusion lists as a way to maximize the rebates they receive from drug companies.
The Federal Trade Commission is reviewing the use of exclusion lists and other industry practices. That review could result in returning those lists to their original purpose or eliminating them altogether, which would be good news for the 37 million Americans of all ages who live with migraine.