The bottom line…

After 22 years with the same insurance, my company recently switched to a more cost effective program.  By reputation, it’s a great insurance.  It’s the same insurance I had as a child but with the changing times, and my jaded experience I was expecting the worst.  So far, I’m grandfathered in with my Tier III biologic drug, but the first specialty pharmacy rep did tell me that “We have to see if we can provide this drug to do or if there is another effective drug you can use.”  I felt a vessel burst in my head with that statement.  I assumed (you know what that means!) that he was talking about dropping me to a lower tiered drug (I’ve failed 4 other biologic drugs on all three tiers) to save money….but alas, I think I was wrong.

Coincidentally, the day I called to order my prescription, the speciality  pharmacy, I now must use, released a press release about the “Saving potential and the challenges” of biosimilars.  Originally, when I learned about biosimilars, I naively assumed it was a “generic” version of my pricey name brand biologic drug.  It is not.  A biologic drug is made using living cells that treat disease, usually by modifying the cells. They are complex drugs and very hard to replicate, which is why they are so pricey.  A biosimilar; however, is not a generic drug, rather it is a similar structure with similar outcomes, BUT it is not manufactured the same way in which a biologic drug is made.  I read in Fortune magazine that a biosimilar can be compared to a snowflake

because each snowflake is unique.  A biosimilar is a “similar” product to the referent biologic drug and deemed by the FDA to have no clinically meaningful differences from the reference product.

What does this mean?  Well, biosimilars will most likely be cheaper than pricey biologic drugs.  There is nothing that insurance companies want more than to drive down costs of drugs.  It will hopefully, give patients who had not be able to obtain biologic drugs previously, may be able to obtain the biosimilar and hopefully, find relief of symptoms from chronic illness.  Exciting, right?

Well, maybe, but I’m skeptical.  It took me 7 LONG YEARS of failing biologic drugs (step therapy) until I was able to find a drug that worked for me.  I still have the occasional flare, but my symptoms are far better controlled now than ever before in my 15 years of living with autoimmune arthritis.  I am not comfortable with changing out my pricey biologic for a drug that is “similar” but not the bioequivalent of my biologic drug.  I may be more willing to try a biosimilar if my current drug fails, BUT I fear that my mini-miracle drug might be ripped away from me because another drug that is “similar” will be cheaper for my insurance. It’s well known that pharmaceutical company prices are outlandish for medication.  People definitely profit off of the sickness of others.  In order to fight this, insurance companies are saying they are getting “creative” to lower costs.  In reality, they are pulling out antiquated step therapy process that was developed over 40 years ago, prior to technological advances in medicine, while providing patients with less choice for life saving/changing drugs.

My new specialty pharmacy states three strategies to “maximize the competitive landscape”.
The first is Plan Design.  My new specialty pharmacy does not like Biologic drug coupon incentive programs.  It states that these coupons help to ensure brand loyalty.  Say what???  Brand loyalty?  That was obviously written by a person who has never had to take a high level drug to be able to function like a human being.  They have never gone in to anaphylactic shock from the first drug that allowed you to see your ankle for the first time in 7 years.  I’m not loyal to a brand name.  I loyal to myself and that means I take a drug that helps me to live a functional life.  I’m not leading an exciting athletic life.  I can’t do that with my body, my goal is to be able to walk up and down the stairs to do laundry, and to stop at the grocery store on my way home from work.  The drug I am currently on does that so I am loyal to myself in making sure I continue to get it.

The second step to “maximize the competitive landscape” is Exclusion Formularies:  Meaning they will exclude certain drugs through step therapy (which I have already gone through with my previous insurance company) before allowing people to access a higher tiered drug that a doctor may prescribe because it is cheaper for the pharmacy.  Insurance companies dictate what drugs patients can take based on cost, regardless of the actual necessity of the drug prescribed by a doctor.  We, the patients, are forced to relent to what the pharmacy will provide and suffer along with the illness until we can prove that the lower cost drug is not effective.

The third step they presented is Patient and Provider Education.  They state that “grandfathering” (as I was) would allow a patient to stay on a medication as long as they are stable.  However, with the arrival of biosimilars that are deemed to have “no clinical signifcant difference” to the referent (costlier) brand name.  They state I will be receiving FREQUENT communication with patients currently taking costlier brand name drugs.  I’m sure I will receive a ton of information relating to biosimilars.  I will have to answer constant phone calls, and/or fill out forms stating that my expensive drug is working, my doctor will have to document the need for my current medication.  This is not “educating” me.  This bullying me to stop taking a costly drug that works for me and take a risk to try a biosimilar so that my current prescription plan pays less for my care.

I am not saying biosimilars are bad.  It is indeed exciting that more medications can help people lead more functional lives.  I am more concerned with what exactly the “differences” that are not clinically significant may be.  These drugs are no joke.  I would not take a drug that may cause various types of cancer and lowers my immune system so I can’t be near sick people without getting deathly ill, without thinking long and hard about my life.  I had no quality of life prior to biologic drugs.  I did not make a decision to take biologics lightly.  I am stable right now and want to stay that way.  I don’t want to be forced to change because my insurance insists my drug is excluded because another drug is way cheaper even when it is not bioequivalent like a true generic drug would be.

I get where insurance companies are coming from.  They run a business.  But as the CEO of my life, I will make sure that they know my health is worth way to me than their bottom line.


2 thoughts on “The bottom line…

Add yours

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

Blog at

Up ↑

%d bloggers like this: