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Are restrictive formularies always bad? One in particular, the Preferred Productive Initiative (PPI) of the Oklahoma state employee health plan Health Choice, seems to differ from the mainstream.
This PPI is a formulary made up of a list of medications that are "preferred" because they are less expensive, have fewer side effects, or are deemed more effective than others by an evaluation group. The list was carefully created and instituted by state medical, pharmaceutical, and administrative personnel.
"Health Choice's pharmacy plan is called a preferred product initiative in lieu of a formulary because its not intended to be a closed situation," said Elgene Jacobs, Ph.D., a pharmacy consultant for Health Choice and program director at the state employees program. Jacobs said that plan members who have already been on a medication before it was designated nonpreferred have the option to continue to take it if their doctors file appeals and gain approval for them. If members choose to take a nonpreferred medication, they can do so if they pay the cost over the comparable preferred medication.
Health Choice's PPI was not begun without difficulties, however. Of the plan's 150,000 members, 42,000 were affected. These members had been told in April about the July 1 change placing their medications on a nonpreferred list. They were encouraged to fill current prescriptions before that date and speak to their doctors about alternatives or appeals to remain on their medications.
Health Choice received about 30 calls a day from members concerned about how the PPI would affect them, and doctors spent time fielding questions and later writing appeals.
Health Choice responded to recent appeals by an APA member requesting that he be able to continue to prescribe a nonpreferred medication for several patients who had been stabilized on it for many months.
Arthur Rousseau, M.D., an Oklahoma psychiatrist in private practice and an APA member, said four of his patients on the Health Choice insurance plan set up appointments to talk to him about the fact that Prozac, the medication they were taking, had become a nonpreferred drug. One was concerned that there was something wrong with Prozac, said Rousseau. He wrote letters to Health Choice requesting that all four patients be allowed to stay on Prozac, and he wrote a letter to the director of the Oklahoma State Insurance Board expressing his concerns about the new policy and the fact that it might be detrimental for some patients.
The company denied three of the four appeals, and the insurance board did not respond to his letter. Rousseau wrote second appeals for the three denied patients, reiterating the fact that these patients had been stable on Prozac for many months and that it would be detrimental to them to switch medications.
After waiting for a couple weeks and not receiving a reply, Rousseau contacted Health Choice. He called five times before he was able to speak with a pharmacist, who told him that his appeals had been granted.
In planning the PPI, Health Choice appointed clinical evaluation groups to review various medications for particular ailments. The groups consisted of general practitioners, psychiatrists from Health Choice, pharmacists from the College of Pharmacy at the University of Oklahoma, and medical directors from the state-employee and Medicaid programs.
Participating physicians indicated that medications like Paxil and Zoloft are as clinically effective as Prozac, said Jacobs, and that it was practical to have patients try those two medications first. If they didn't work, the patients could then try Prozac.
Though the instigation of the PPI did alarm members and create more work for doctors and for Health Choice for a couple months, the number of calls has diminished drastically, said Jacobs. "We have been able to address the concerns that arose, and it has gone fairly well. Because this is not a closed formulary, physicians can be patient advocates. Members, physicians, and Health Choice employees have been able to work it out."
Jacobs said that of about 1,500 appeals (this number includes general medical as well as mental health), 500 have been granted. He said several of Rousseau's first appeals were originally denied because there was no documentation of previous experience with a preferred product, but that more consideration was given to his follow-up appeals, which were granted.
"If we can ascertain that a patient has been stabilized three to five months, we will give the authorization for continuing to use a medication at the standard pharmacy benefit," said Jacobs. Those who want to begin to use a nonpreferred medication can do so and pay the difference over the standard benefit.
As for Rousseau, he said that psychiatrists can influence the policies of plans like Health Choice. "If we advocate for patients, we can make a difference," he said.