General Discussion
Related: Editorials & Other Articles, Issue Forums, Alliance Forums, Region ForumsRegarding formularies in single payer systems...
I briefly read the posts from someone who was complaining about a DMD medication for MS being unavailable on his insurance plan due to it not being on the formulary:-
http://www.democraticunderground.com/10024690196
A few people made the remark that even single payer systems have formularies, and that therefore those drugs might be unavailable even in a system like Canada's or Britain's or Australia's.
The poster doesnt mention the name of the medication but I presume it is one of the more popular DMDs (Gilenya, Tecfidera, Aubagio . All of those drugs are currently available on the Pharmaceutical Benefits Scheme run by the Australian Government. I believe that they are all available on the British NHS as well.
In Australia, that means that the maximum cost to the consumer is $36.90 AUD a month or thereabouts. In Britain the cost would be 7.85 GBP.
The actual cost to the Australian government is about $25,000 USD a year for these medications, still much less than the $45,000 USD charged to US insurance companies. The difference is that in single payer systems, the buyer power is concentrated in the hands of the government, and this gives the government substantial power to put pressure on drug companies as to pricing.
While there are drugs that are not covered by the PBS, generally those medications that can demonstrate efficacy are covered. Those that aren't tend to be in market sectors where there is a tremendous proliferation of products with none having much advantage over others (classic example would be antidepressants, these days there are hundreds of them).
geek tragedy
(68,868 posts)part as to why it was denied.
shaayecanaan
(6,068 posts)There are only a few DMDs for MS that can be taken orally. They are all hideously expensive (around 50-60K a year at US retail prices). It doesnt really matter which one it is, frankly, I can see why an Insurer would want to avoid supplying any one of them at all. Its a dead loss for them.
As I understand it, the minimum standard under Obamacare is that formularies must include one drug from each class. Thats a pretty low benchmark. Aside from that it is up to individual states to decide what drugs must be included in formularies. In theory, a formulary that allowed patients access to interferon alone would satisfy the requirement to include one DMD.
http://www.forbes.com/sites/scottgottlieb/2013/12/09/no-you-cant-keep-your-drugs-either-under-obamacare/
As stated in that article, the only hope is that the drug companies start muscling the states to include their specialty drugs in formularies.
Crunchy Frog
(26,701 posts)the drug was stated to be Aubagio, and therefore on the formulary.
shaayecanaan
(6,068 posts)I have to say it is rather hard on the consumer to expect them to stay on top of all this. Particularly when the lists arent complete.
Hoyt
(54,770 posts)I think I read the coverage starts in April.
That's the newest MS drug. I hope the poster gets to talk to someone higher up in the food chain at his insurance company who might have more perspective on this. He said the injectable forms were covered, so that us still an option, although not their preference. Also, the NHS approved it after the drug company cut the price (don't know details).
shaayecanaan
(6,068 posts)Aubagio wouldn't do much for patients suffering from primary progressive MS. In fact none of the DMDs have a dramatic effect on PPMS, so I presume that the poster's wife was suffering from RRMS.
Mojorabbit
(16,020 posts)shaayecanaan
(6,068 posts)It is approved for spms post rrms where the patient still has relapses. Point taken though.
Gormy Cuss
(30,884 posts)That's what makes a difference. When there's only one buyer in a market, the negotiating power of that buyer is enormous.
ProSense
(116,464 posts)...true of Medicare, Medicaid and VA. Here is information on formularies in Ontario and British Columbia
http://www.health.gov.on.ca/en/pro/programs/drugs/odbf_mn.aspx
http://www.health.gov.bc.ca/pharmacare/benefitslookup/faces/Search.jsp
Obamacare: It's Obama's signature achievement
http://www.democraticunderground.com/10024695694
shaayecanaan
(6,068 posts)is that it is statutorily forbidden from negotiating drug prices with the companies and so ends up paying through the nose compared with what the VA ends up paying for the same drug.
According to the leaked Pharma memo, Obama promised the drug companies he wouldn't change this in exchange for their non opposition to Obamacare.
http://m.huffpost.com/us/entry/258285
nadinbrzezinski
(154,021 posts)we need a single negotiator. The insurance companies will fight it because that is a cash cow, so will big pharma.
We pay, on average, quite a bit more for meds than other countries.
shaayecanaan
(6,068 posts)That the us effectively subsidises the rest of the worlds drugs. The drug firms make their profits in the us so they can take a hit elsewhere.
nadinbrzezinski
(154,021 posts)I pay 20 for metmorfin in Mexico City, same dossage. I pay 40 in the states with insurance, without it...700, for a monthly supply.
shaayecanaan
(6,068 posts)They would just break the patents, if it meant not dying.
Reminds me of album prices. Before cd burners, the internet and parallel imports, the cost of an album was 32.99 in Australia. It was one third of that price in singapore, to discourage people from buying counterfeits which werent available in australia. Essentially australian consumers were being punished for living in a country that upheld IP rights.