Regarding formularies in single payer systems...

[shaayecanaan]

I briefly read the posts from someone who was complaining about a DMD medication for MS being unavailable on his insurance plan due to it not being on the formulary:-

http://www.democraticunderground.com/10024690196

A few people made the remark that even single payer systems have formularies, and that therefore those drugs might be unavailable even in a system like Canada's or Britain's or Australia's.

The poster doesnt mention the name of the medication but I presume it is one of the more popular DMDs (Gilenya, Tecfidera, Aubagio . All of those drugs are currently available on the Pharmaceutical Benefits Scheme run by the Australian Government. I believe that they are all available on the British NHS as well.

In Australia, that means that the maximum cost to the consumer is $36.90 AUD a month or thereabouts. In Britain the cost would be 7.85 GBP.

The actual cost to the Australian government is about $25,000 USD a year for these medications, still much less than the $45,000 USD charged to US insurance companies. The difference is that in single payer systems, the buyer power is concentrated in the hands of the government, and this gives the government substantial power to put pressure on drug companies as to pricing.

While there are drugs that are not covered by the PBS, generally those medications that can demonstrate efficacy are covered. Those that aren't tend to be in market sectors where there is a tremendous proliferation of products with none having much advantage over others (classic example would be antidepressants, these days there are hundreds of them).

[geek tragedy]

1. without knowing the name of the medication it's pretty much speculation on anyone's

part as to why it was denied.

[shaayecanaan]

2. There are only a relative handful of medications

There are only a few DMDs for MS that can be taken orally. They are all hideously expensive (around 50-60K a year at US retail prices). It doesnt really matter which one it is, frankly, I can see why an Insurer would want to avoid supplying any one of them at all. Its a dead loss for them.

As I understand it, the minimum standard under Obamacare is that formularies must include one drug from each class. Thats a pretty low benchmark. Aside from that it is up to individual states to decide what drugs must be included in formularies. In theory, a formulary that allowed patients access to interferon alone would satisfy the requirement to include one DMD.

http://www.forbes.com/sites/scottgottlieb/2013/12/09/no-you-cant-keep-your-drugs-either-under-obamacare/

As stated in that article, the only hope is that the drug companies start muscling the states to include their specialty drugs in formularies.

[Crunchy Frog]

9. I believe in one of the posts on the subject

the drug was stated to be Aubagio, and therefore on the formulary.

[shaayecanaan]

12. i couldnt find aubagio on their list

https://www.usi.edu/hr/benefits/pdfs/Anthem%2520Rx%2520Formulary.pdf

I have to say it is rather hard on the consumer to expect them to stay on top of all this. Particularly when the lists arent complete.

[Hoyt]

3. The British NHS just recently approved Aubagio, and only for patients with certain types of MS.

I think I read the coverage starts in April.

That's the newest MS drug. I hope the poster gets to talk to someone higher up in the food chain at his insurance company who might have more perspective on this. He said the injectable forms were covered, so that us still an option, although not their preference. Also, the NHS approved it after the drug company cut the price (don't know details).

[shaayecanaan]

6. It would probably only be approved for RRMS...

Aubagio wouldn't do much for patients suffering from primary progressive MS. In fact none of the DMDs have a dramatic effect on PPMS, so I presume that the poster's wife was suffering from RRMS.

[Mojorabbit]

10. I have secondary progressive MS and Aubagio is working for me. nt

[shaayecanaan]

11. according to the fda

It is approved for spms post rrms where the patient still has relapses. Point taken though.

[Gormy Cuss]

4. Yes--in single payer systems the cost of the drug is generally lower,

That's what makes a difference. When there's only one buyer in a market, the negotiating power of that buyer is enormous.

[ProSense]

5. That's

The actual cost to the Australian government is about $25,000 USD a year for these medications, still much less than the $45,000 USD charged to US insurance companies. The difference is that in single payer systems, the buyer power is concentrated in the hands of the government, and this gives the government substantial power to put pressure on drug companies as to pricing.

...true of Medicare, Medicaid and VA. Here is information on formularies in Ontario and British Columbia

http://www.health.gov.on.ca/en/pro/programs/drugs/odbf_mn.aspx

http://www.health.gov.bc.ca/pharmacare/benefitslookup/faces/Search.jsp


Obamacare: It's Obama's signature achievement
http://www.democraticunderground.com/10024695694

[shaayecanaan]

7. My understanding of Medicare (US)

is that it is statutorily forbidden from negotiating drug prices with the companies and so ends up paying through the nose compared with what the VA ends up paying for the same drug.

According to the leaked Pharma memo, Obama promised the drug companies he wouldn't change this in exchange for their non opposition to Obamacare.

http://m.huffpost.com/us/entry/258285

[nadinbrzezinski]

8. I made this point repeteadly yesterday

we need a single negotiator. The insurance companies will fight it because that is a cash cow, so will big pharma.

We pay, on average, quite a bit more for meds than other countries.

[shaayecanaan]

13. i read in the financial times somewhere

That the us effectively subsidises the rest of the worlds drugs. The drug firms make their profits in the us so they can take a hit elsewhere.

[nadinbrzezinski]

14. Would not surprise me.

I pay 20 for metmorfin in Mexico City, same dossage. I pay 40 in the states with insurance, without it...700, for a monthly supply.

[shaayecanaan]

15. I suppose if the mexicans cant buy it

They would just break the patents, if it meant not dying.

Reminds me of album prices. Before cd burners, the internet and parallel imports, the cost of an album was 32.99 in Australia. It was one third of that price in singapore, to discourage people from buying counterfeits which werent available in australia. Essentially australian consumers were being punished for living in a country that upheld IP rights.