For many years he tried to manage with lifestyle. Despite doing great there (normal weight, eats healthy, improved fitness), he still had high Uric Acid & gets frequent, terrible flare-ups requiring anti-inflammatories & colchicine. He has bad genes. /2pic.twitter.com/hmGsdlS0jD
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So, after many years of just treating attacks--crippling him for days each-- he reluctantly agreed to a daily preventive med called allopurinol. As luck would have it, he was the rare person who got a bad reaction; developed flu-like symptoms within a week that could be... /3pic.twitter.com/Rmua5fCJUv
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...a sign of severe/life-threating allergy. He stopped the med, of course! Luckily for him, there is another med, Urolic, that has a similar effect/benefit but less likely to cause this allergy. Unfortunately, at that time (about 4 years ago), Uloric was available only... /4
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....as a brand-name and quite expensive ($300-ish/mo. full price). We jumped through a few hoops and he got it approved by the plan. He's done great since then--normal uric acid & very few, if any, serious gout attacks. The Uloric has been somewhat expensive, but... /5pic.twitter.com/23nRsCTYZ5
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...he has found coupons that have reduced out-of-pocket costs for him. Fast forward to 2019: Uloric has now gone generic....YAYYY! Several manufacturers are making it and pricing coming down to near $100/mo; not cheap but 1/3 the brand! Back to the prior-auth: /6
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Jimmy apparently switched insurance plans ($1200/mo for family) in 2019 which doesn't know his history. So, the first refill of Uloric, they want justification for why he needs it; fair enough. The plan suggests using a website for a "streamlined" online PA. /7pic.twitter.com/pH2S54OTZB
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The webpage, once loaded, just says "denied" -- no ability to edit or submit any response. So, my nurse calls the phone number & after 20 min. hold is told THEY don't process this. They now using a third-party (? PBM) for approvals. A different phone number is given. /8pic.twitter.com/vfzjsxgIlw
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After another long phone hold, they fax us a form to complete. We report his history of gout & reaction to allopurinol & good response to Uloric. They do ask has he taken any other meds, including colchicine, for prevention? (pharmacology weeds upcoming, but important) /9pic.twitter.com/LDyaf5AFve
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Jimmy HAS previously taken colchicine for flares (somewhat helpful) & for a few months while starting Allopurinol & Uloric. Historically, this med was used for prevention by itself. But, for many years nearly every expert/guideline says... /10
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...it's NOT a good choice long-term compared uric acid lowering meds like Allopurinol or Uloric; it shouldn't be used by itself in most patients!!! https://onlinelibrary.wiley.com/doi/full/10.1002/acr.22275 … Another med (Probenecid) is an even worse choice for prevention. That's the whole list! /11
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So, I'm feeling pretty good about this getting approved because, really, what is the other choice here? Within about a week, we get a response: DENIED! Approval of Uloric requires the patient must first "fail" two other preventive meds, suggesting colchicine instead. /12pic.twitter.com/fpD5uLRetg
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I know what you are probably thinking..."Insurance plan doesn't want to pay for the more expensive med" Not so fast... Colchicine, although a very old med, skyrocketed in price several years ago due to some complex FDA stuff: https://www.mdmag.com/medical-news/why-is-colchicine-so-expensive-now … /13
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There are a few options now (1 generic) but the plan suggested brand "Mitigare" @ $120/mo. (subject to approval of course! I'm not kidding) Remember, Uloric is now generic & $100/mo. (a plan was previously paying 3x for this med!) So, clearly this... /14
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...is NOT about forcing a patient to take a cheaper med! But why? It is very possible--speculation here-- there is some type of PBM "rebate" (aka. kickback) at play here. I've written about previously: https://threadreaderapp.com/thread/1128855972091502592.html … /15pic.twitter.com/S8hWH2K8K6
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After screaming a few times, we wrote a letter to explain why colchicine is not a good choice & desire to continue Uloric. But, again...DENIED! At this point, I request a "provider-to-provider" call because the algorithm isn't working. (or is it?) The PBM tells us... /16
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...they don't do "clinical" reviews in-house. They rely on a different company (medical consultants?) for that. (that's the 3rd third-party if keeping track). They give us another phone number (only). We call it. They send us a form. (You know the routine!) /17pic.twitter.com/0niLxrNXjJ
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It's basically the same med history form as the initial! We dutifully fill it out (again) and fax it back. Within a week or so...DENIED! (After cooling off for a few days) We call again to request a provider-to-provider call but told by fax... /18
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"This case is closed and beyond the 7-day window to appeal. It was reviewed by a (nameless) board-certified Rheumatologist." The fax educated me by providing a list of articles about gout management. Although I know this info well, I reviewed them. Some excerpts... /19pic.twitter.com/CCiMDGjUnf
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"American College of Rheumatology and European League Against Rheumatism guidelines recommend uric acid-lowering therapy (Allopurinol or Uloric!) until serum uric acid is maintained at ≤6 mg/dl." COLCHICINE DOESN'T DO THIS!!! /20pic.twitter.com/Ny43giOmbY
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Now I'm fightin' mad, so call to request the name & license number of the physician who reviewed the case. Predictably a rep tells me, "I'm sorry, sir, we cannot provide that information. Our physicians are anonymous." Me: "Is there any recourse here?" /21
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"We suggest you talk w/ the insurance plan". [CLICK] So, Jimmy and I are obviously not happy. Despite spending enormous time & effort, I feel like I failed. Could I have used better/different/more words to get my patients what they needed? I dunno. Maybe. /22pic.twitter.com/3RxXRjG6D7
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Jimmy will have to decide to pay for Uloric (luckily cheaper now), or do a trial of another medication which isn't ideal--or cheaper!--by any standard of care. I don't know what he will do, but that's the story. Next patient. /donepic.twitter.com/Py0CwkpAn8
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Added comments based on feedback: Frankly, I am a bit afraid to name the ins. co. or PBM publicly. As you can see, they already have tremendous power to make my patients’ (via my recommendations!) life a living hell. I suspect I’d end up on a “bad doctor” list quickly!pic.twitter.com/qrfN50Ad0i
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I’ve also been advised by a few attorneys—not my first rodeo de ranting....haha—to not share such details. Even it’s all 100% accurate, a lawsuit is not something I can afford. (They can!)
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If wanting to deal with yet more bureaucracy, we could report this companies to state insurance commissioner. But I very much doubt they’d get involved in this case—nothing illegal or fraudulent here. And, they certainly won’t put the screws to a VERY large health plan!
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Jimmy will get the med; he can thankfully afford it at $100/mo. But calculating the amount of time = money spent on this nationwide, everyday is almost incalculable. But it’s all “covered” & part of the “plan”, so....
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