Changes to BCBSRI prescription plan raises concerns

Providence, RI – Last November, Blue Cross Blue Shield of Rhode Island decided to cut costs by not paying for brand name drugs when there was a cheaper generic version. But some residents say there are no alternatives to the medications they need. Now they're faced with paying the full market price or going without their medicine.

Catherine Lewis has a problem. Six years ago, Lasik surgery improved her vision, but it left her with a painful side effect.

"When I first had the surgery and we didn't know what it was, it went so bad that it was like hemorrhage behind my eye and they thought they'd have to do the surgery over," she says.

Her doctors finally discovered that the problem was coming from Lewis's dry eyes. She no longer had enough tears to keep them moist. Her optometrist recommended Restasis- the only eye drop that helps produce tears.

"I'd take the cap off, put one drop in each eye, and close my eyes with my head back for minutes," she says," and then I just open my eyes and I feel great."

That is, until Blue Cross Blue Shield took Restasis off the list of drugs it will pay for. Lewis used to have a 30 dollar co-pay for the eye drops, now she has to pay the full price- $340 for a month's supply.

"My doctor himself called me and I asked him if there's anything else I could take,"she says. "And he said no, the drug is too new, there's no generic form and there's nothing comparable at all out there."

Blue Cross doesn't allow appeal rights for medication that's been removed from its list of covered drugs. So Lewis faces two options- give up the medication or pay up. Now she's stretching out the last drops of her Restasis,scrounging for stray containers in her car or her purse. But Lewis is down to her last dose, and not sure what to do.

Dr. Augustine Manocchia, the chief medical officer at Blue Cross Blue Shield, says the health insurance company has gotten a couple of complaints from eye physicians about the fact that Restasis was removed from its list of covered drugs. It's one of the medications Blue Cross is looking at in terms of an appeals process.

Manocchia says 19 percent of the company's health care dollars cover prescription costs. Getting rid of some brand name drugs is one way to make health insurance more affordable. And most doctors can find an identical, cheaper alternative to the drugs they were prescribing.

As for doctors who can't,"What I've said to them is, if you can provide us with evidence based, nationally supported, peer reviewed literature that supports your contention about a particular drug, we certainly will entertain that idea," he says.

The Service Employees International Union's Patrick Quinn says he has a stack of complaints from 150 of his union members who've seen their drug costs skyrocket.

"Many people have already been through this route," he says,"and arrived at this drug because it's the prescription drug that has the most positive impact and the least negative effects. "

Rhode Island Health Insurance Commissioner Chris Koller says he's keeping an eye on Blue Cross and is noticing relatively few complaints- but he is concerned about people like Catherine Lewis who can't buy a generic version of their medications. He says Blue Cross told him the changes were just for brand name drugs that had cheaper, chemically identical replacements.

"This particular woman who you're talking about where not only is there no identical drug, there's no equivalent drug," he says, "that would be something different from what blue cross told us they would do. And we would want to pursue that."

Blue Cross Blue Shield is thinking about allowing appeals for some of the medications it's received complaints about, but the Service Employees International Union thinks that isn't enough. It's talking with members of the General Assembly about legislation that would give patients the right to appeal changes to their prescription coverage.

In the meantime, Catherine Lewis says she'll just have to break down and buy those $340 eye drops, making each dose last as long as possible.

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