It wasn't legal when Bayer did it, so why does Coventry?

Bayer Fined $97.5M For Kickbacks To Switch Glucose Monitors

I read that article a few weeks ago and it started my thinking about my insurance company and the coverage provided for insulin and test strips. You get lower copays (but NOT the lowest generic tier copay) for using insulin and glucose monitors and supplies from certain manufacturers.

My insurance company is Coventry of Kansas and they “encourage” the use of insulin from Eli Lily and the OneTouch meters and supplies. By encourage, I mean that you are perfectly free to use whatever brand you want, but if it is not one of the “preferred” brands, your copay is $25 higher per month on each item. That adds up to $300 a year, for me anyway, since I found I have to use Novalog in my pump as opposed to Humalog.

The biggest issue I have is that it seems there must be some type of agreement in place. What is the difference between what Bayer did and what Coventry and Eli Lily are doing? Diabetes seems to be the only condition with this type restriction. Most medication copays are set by the relative cost of the medication, or so Coventry says.

Except for these… the copays for these drugs seem to be based upon the condition of the patient. Coventry’s position is that they have found diabetes drugs from these manufacturers to be less costly. Then why can’t we get the $10 generic copay on them as opposed the $30 mid-tier?

Novalog and Humalog are almost identically priced, so the lower cost argument does not hold water. I went and looked at my prescription history. Novalog comes in at $91.52/vial ($55 copay) and Humalog comes in at a shockingly low $91.05/vial ($30 copay).

Why is this type of behavior on the part of manufacturers and insurance companies legal? How does it differ from what Bayer was doing? I feel this is very similar to the horror stories you used to hear about. Where a treatment for a condition isn’t even mentioned if the patients insurance wouldn’t cover it. I just can’t see the difference.

Now, I suppose I have made some rather strong accusations in this. This is my opinion and I have documentation to back up my numbers.

Scott,
My insurance is the same. They will only cover the Free Style meters and strips!
I too feel as you do, there has to be some type of “agreement” or kickback to the insurance companies for this.

pretty bad…even worse–it happens in hospitals too. When I was in the hospital–my family had to bring one of my medications fromhomeasthe hospital did not “carry that brand”–sickning how they get away with it

Read Evan Levine’s 2003 book “What your Doctor Won’t or Can’t Tell you” He describes the insurance/hospital pharmaceutical web in detail. (Including why hospitals only stock certain brands of meds). He is a noted cardiologist in New York. Fascinating.

I can relate. My Apidra and Freestyle products are highest tier ($50 copay) while One Touch would be mid-tier ($30) for me. And there isn’t a test strip or insulin on the generic ($10 low tier) for my plan.

What really ticks me off is the oh-so-careful, noncommittal wording when you call the insurance company to discuss coverage. You say, “I need XYZ” or “my doctor says I need XYZ” and they answer with a sort of condescension. “Well, we will have to determine if XYZ is medically necessary for your condition” or “we do not have enough information to say whether XYZ will be the right fit for you at this time.” Just once I’d like to hear the truth: “We know you need XYZ, but we’re not covering it, so deal with it.” I’d be angry, but at least I’d feel like they’re not telling me that they know better than me or my physicians!