Asking more than 5,100 North Carolina state employees or retirees to switch from a popular anti-clogging drug to less expensive alternatives on Jan. 1 is causing criticism from patient advocacy groups.
In November, the N.C. State Health Plan and its pharmacy benefit manager, CVS Caremark, sent letters to members who use Eliquis, a hugely popular drug produced since 2012 by Bristol Myers Squibb. They were instructed to switch to either Xarelto or generic warfarin, which are also prescribed for patients with potential blood clots.
The move followed a change in a CVS Caremark “formulary” that details which drugs are covered by specific health plans. About 150,000 patients nationally are affected by that change. The nonprofit Partnership to Advance Cardiovascular Health sent a letter to CVS Caremark on Dec. 16, calling it a “dangerously disruptive” decision that would increase patients’ risk of stroke and death.
Eliquis and Xarelto, which was developed by Bayer and Johnson & Johnson, each typically costs more than $500 a month for those without insurance. Warfarin is priced at a few dollars a month, but requires more stringent monitoring and may not be as effective, according to many physicians.
State Treasurer Dale Folwell, who oversees the health plan, says balancing the needs of health plan members with budget pressures is a constant battle. The plan’s prescription drug costs are increasing by more than 10% annually, or more than three times the rate of overall inflation in recent years. Meanwhile, state lawmakers have limited their funding for reimbursements for the plan to about 4% annual increases, he said.
The State Health Plan had a $300 million deficit in its 2021 fiscal year with revenue of $3.7 billion and expenses of $4 billion, according to a board meeting report last week. An additional $1.4 billion of losses are projected over the next four years, which would leave the plan with a net deficit of more than $500 million by 2025. It now has a surplus of about $680 million.
North Carolina has been “highly successful” in arranging rebates with drug companies in recent years as a means of limiting the cost to members, Folwell says. But the system faces increasing pressure because fewer members are contributing to the plan as growth in state employment stagnates and more staffers enter retirement, he says. He favors efforts to restrain prices charged U.S. consumers by pharmaceutical companies.
The changes involving Eliquis show the dangers of an insurer getting involved in a patient-physician decision, says Beth Waldron, communications director of the National Blood Clot Alliance, a small nonprofit founded in North Carolina. The group is among 14 patient advocacy groups that are protesting the decision, she says.
“I’ve been a patient advocate for 18 years and I’ve never seen folks coming together so quickly,” she says. “It really has struck a nerve.”
Waldron, who takes Eliquis herself as a State Health Plan member, received a Nov. 11 letter from CVS Caremark noting that her current medication is “no longer covered by your plan” after Jan. 1. She was told she could either switch to warfarin or Xarelto, which will be covered, or plan to pay 100% of the cost of Eliquis.
“We have good quality studies showing that Eliquis is safer and more effective than the alternatives,” Waldron says. Blood thinners have a unique classification because their use can lead to fatal internal bleeding.
The health plan later told Waldron to file for an exemption, which she says may require showing that an adverse event such as a clot occurred after she switches to a less expensive option. Continuing with Eliquis also will likely require renewed approvals from physicians, she adds.
The health plan is telling members affected by the change that they can seek exemptions “as clinically appropriate based on each member’s specific circumstance. This includes a one-time 30-day override beginning Jan. 1 that the pharmacies may receive for members attempting to fill Eliquis,” says Dan Way, the treasurer’s communications manager.
