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December 2, 2003

Insurance/Costs

Question from Orem, Utah, USA:

My question is about Lantus. It's open enrollment season for private insurance. Between my husband and me, we have several choices of health insurance plans through two different companies. Yet on all of them (not surprisingly) prescription co-pays are going up significantly, especially non-formulary drugs. I take Humalog and Lantus, and for all of the plans we have available, Lantus is a non-formulary drug. During my last doctor appointment, I asked my doctor for an alternative - since the copays will be going up to $35/month for just the Lantus, and he said I should stay on the Lantus and there wasn't an equally effective alternative. He also was quite surprised when I told him the Lantus was non-formulary. My question is, why is Lantus non-formulary? Do you consider there to be a perfectly acceptable alternative? Is it because Lantus is still relatively new, and if so, do you think that Lantus will eventually become a formulary drug? Do you think staying on Lantus is worth an extra $300 a year out of pocket versus the alternative?

Answer:

First, full disclosure: I work for an HMO. Second, only a medical professional can advise you if Lantus is the right treatment for you. Whether or not a pharmaceutical is placed on a plan’s formulary can be driven by several factors. First, does the plan have a contractual relationship with the manufacturer setting a discounted price for the item? Are there other, cheaper alternatives that will provide a similar benefit to a large portion of the patients? How effective is the drug compared to cheaper alternatives? I suggest you have the network provider who prescribes the Lantus for you contact the medical director to seek a benefit exception allowing coverage of the Lantus for you.

DSH