California demands coverage for drugs with over-the-counter competitors

State regulatory guidelines would allow insurers to charge higher co-pays and could mean extra paperwork for physicians.

By Robert Kazel, AMNews staff. April 28, 2003.

At least one state is telling insurers that access to prescription drugs is nothing to sneeze at.

The California Dept. of Managed Care, which regulates the state's HMOs, has sent an advisory notice to health plans stating they should not end coverage of a whole class of allergy drugs simply because one medication -- Claritin (loratadine) -- has gone over-the-counter.

Right now, this warning primarily applies to users of nonsedating antihistamines. The allergy drug Claritin went over-the-counter in December 2002, and under the guideline issued by the California agency, payers cannot automatically decline to reimburse patients for competing products such as Zyrtec (certirizine hydrochloride) and Allegra (fexofenadine hydrochloride).

The warning to payers was "a precautionary action" intended to prevent insurers from unfairly halting access to whole classes of drugs, in case they were considering it, and could influence other states because "California patient rights laws are a model for the nation," said Steve Fisher, deputy director of the state managed care department.

The advisory was spurred by some complaints to the agency's hot line from patients who were beginning to have trouble getting insurance coverage for the drugs they wanted.

The state's action is reassuring, said Jeffrey Kishiyama, MD, president of the California Society of Asthma, Allergy and Immunology. Dr. Kishiyama said doctors had been hearing "rumblings from insurance companies that they would limit all antihistamines" after Claritin became available on store shelves. He said allergists in the state had asked managed care regulators to look into the matter last fall.